LIBRARY OF CONGRESS. 



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B-9 



UNITED STATES OF AMERICA. 




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Copyright 

WILLIAM WOOD & COMPANY 

18S0 



Trow's 

Printing and Bookbinding Company 

201-213 East xzth Street 

New York 






PREFACE 



In the following treatise my aim has been to present, in 
text-book form, a picture of diseases of the ear as they have 
appeared to me in private and hospital practice. I have 
occasionally, it is true, drawn my illustrations from the 
published experience of others, but in the main I have fol- 
lowed closely the plan of using only the material stored up 
in my own case-books, and of describing only those methods 
of treatment which I have tested and found both safe and 
efficient. 

A. H. B. 



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CONTENTS. 



CHAPTER I. 



PAGE 

Sketch of the Physiology of the Organ of Hearing 1 



CHAPTER II. 

Examination of the Patient 17 

Tests of the hearing-power 17 

Instruments and methods of examination 20 

Ear-specula 20 

Reflectors 22 

Introduction of the speculum and use of the reflector 24 

instruments used in the examination of the ear 28 



CHAPTER III. 

Diseases of the Auricle 35 

Eczema 35 

Inflammation of the auricle 39 

Hasmatoma auris 40 

New-growths 51 

Miscellaneous diseases 53 

Congenital malformations 55 

CHAPTER IV. 

Diseases of the External Auditory Canal Zl 

Impacted cerumen 57 

Acute circumscribed inflammation 65 

Acute and chronic diffuse inflammation 74 

Desquamative inflammation 86 

Ulcers, polypoid growths, and caries 92 

False membranes in the auditory canal 98 



VI CONTENTS. 

PAGE 

Syphilitic ulcers and condylomata 104 

Foreign bodies 109 

Wounds 113 

New-growths , 114 

Hyperostosis ; exostoses; bony closure 114 

Cancer 118 

Sarcoma 120 

Cysts 133 

CHAPTER V. 

Methods of Examining the Middle Ear 125 



CHAPTER VI. 

Diseases op the Middle Ear (Non-purulent Forms) 141 

Preliminary remarks 141 

Affections of the Eustachian tube 142 

Acute and subacute inflammation of the middle ear 151 

Catarrhal inflammation of the middle ear 153 

Chronic subacute catarrh 193 

CHAPTER VII. 

Diseases op the Middle Ear (Purulent Forms) 196 

Acute purulent inflammation 196 

Acute inflammation of the posterior fold 224 

Syphilitic disease 227 

Chronic purulent inflammation 230 

Simple uncomplicated cases 237 

Proliferative cases 246 

{Foreign bodies in the middle ear) 258 

Cases in which the bone is involved , 259 

CHAPTER VIII. 

Fractures op the Temporal Bone 278 

CHAPTER IX. 

Diseases op the Mastoid Process 296 

I. Affections in which the antrum is the part chiefly involved 301 

II. Acute inflammation of both the antrum and the pneumatic spaces 328 

III. Inflammation of the external periosteum of the mastoid process 355 



CONTENTS. Vll 
CHAPTER X. 

PAGE 

Miscellaneous Conditions of the Drum-membrane, Ossicles, and Tym- 
panic Cavity 370 

Atrophy of the membrana tympani 370 

Horny growth of the membrana tympani 371 

Vascular growth of the membrana tympani. 372 

Deformed drum-membrane 372 

Absence of the hammer 372 

Hook-shaped manubrium mallei 373 

Ruptures of the drum-membrane 373 

New-growfchs of the middle ear , . . 374 

Hyperostosis. 374 

Vascular growths 375 

Malignant tumor 382 

Subjective and objective systolic murmurs 386 

Otalgia 387 

CHAPTER XI. 

Different Forms of Aural Disease in wnicn the Labyrinth is believed 

to be Involved 388 

INDEX 405 



DIAGNOSIS AND TREATMENT 



OF 



DISEASES OE THE EAE. 



CHAPTER I. 
SKETCH OF THE PHYSIOLOGY OF THE ORGAN OF HEARING. 

It has often been said, and with entire justice, that no other part or organ 
of the human body is so beautiful in structure as the ear. Its tympanic 
membrane, its chain of ossicles, its wondrous labyrinth containing cavities 
within cavities and thousands of vibratile cords — all these together go to make 
up an organ of exquisite architectural beauty, and one that is marvellously 
adapted to the purpose for which it is designed. This delicate organ, with 
its multitude of fragile elements, needs the most ample protection, and we 
find it, accordingly, buried deep in the bone whose name (petrous) tells the 
story of its hardness. Inaccessible, as it is, to the eye, the wondrous inte- 
rior of the labyrinthine cavities for a long time remained an almost unex- 
plored territory. What we know to-day is the result of years spent in un- 
tiring researches, attended with repeated failures. One, by one, however, 
the disputed points have been made clear, and we may now safely assume 
that the minute anatomy of the semicircular canals, vestibule, and cochlea 
is as accurately determined as that, for example, of the eye. 

The ear in mammals consists of three different cavities — the external au- 
ditory canal, the tympanum, and the labyrinth (Fig. 1). The first cavity is 
nearly cylindrical in shape ; at one end it communicates with the outer 
world by a broad, free opening, while at the other it is entirely shut off 
from the cavity beyond (tympanum) by a thin, inelastic membrane — the 
membrana tympani [M T). The second cavity, so far as the naked eye can 
see, is a closed cavity, filled with air, which, through the medium of a mi- 
nute canal (the safetv-tube of the Eustachian canal), remains at the same de- 
1 



DIAGNOSIS AND TREATMENT OF 



gree of density as the air on the outer side of the membrana tympani (Biidin- 
ger) ; or, in other words, the atmospheric pressure upon the outer side of 
the membrana tympani and that upon the inner side exactly counterbalance 

each other. The length and 
height of this cavity are very 
nearly equal, but the breadth 
is much less than either. The 
outer side of this peculiarly 
shaped cavity is composed chief- 
ly of the membrana tympani, 
while the inner is a somewhat 
dome-shaped surface of bone, 
covered of course with mucous 
membrane. In this inner wall 
of the cavity are two openings— 
the one oval in shape, the other 
round — which lead by separate 
passages into the last cavity or 
system of cavities of the ear — 
the labyrinth. In the natural 
state these openings are closed, 
the upper one by the foot-plate 
of the stirrup, the lower by a 
delicate membrane (membrana 
tympani secundaria). The con- 
necting link between the vibra- 
tions of a' : in the first cavity 
(or exteual auditory canal) and 
the auditory nerve, which is 
spread out in a portion of the 
third cavity (labyrinth), is form- 
ed by a chain of three ossicles, 
which arch the space separating 
the inner from the outer wall of the second cavity (tympanum). It is there- 
fore essential to clearly understand the mechanism of these ossicles before 
we can discuss intelligently the more complicated mechanism of the laby- 
rinth, and especially of that part of it called the cochlea. 

Let us first take the sea-turtle and examine the simpler auditory appa- 
ratus (see Fig. 2) which we find in that animal. Here the substitute for 
the membrana tympani is situated almost immediately beneath the surface 
of the hard skin or shell on the side of the head, this animal having no ex- 
ternal auditory canal. This substitute is nothing more nor less than the 
flaring end of a slender bone, about two inches in length, whose other end, 
likewise somewhat flaring, terminates in the labyrinth. This slender rod 




Fig. 1. — Diagram showing the Relations of the Ossicles 
to the External Auditory Canal and Labyrinth : T", cavity of 
the tympanum; L, labyrinth ; MA E, meatus auditoriusex- 
ternus ; II, hammer ; A, anvil ; S, stirrup ; M T, membrana 
tympani ; F B, fenestra rotunda. 



DISEASES OF THE EAE. 



(columella) lies, throughout almost its entire length, in a bony canal, and 
fits it so accurately that the only possible motion which can be communi- 

Pressure made at 



cated to the rod must be in the direction of its length. 




Fig. 2.— Diagram of Sea-Turtle's Ear : T, tympanum ; L, labyrinth ; c, columella. 

the outer end causes the inner end of the rod to project to a corresponding 
degree into the labyrinth ; and, the moment the pressure is withdrawn, the 
rod, by reason of the highly elastic ligaments which hold it in place, in- 
stantly returns to its original position. 

The sea-turtle, then, furnishes us with a good example of the simplest 
substitute for the chain of ossicles, while at the same time the piston-like 
action of the rod throws out a hint as to the possible mechanism of the 
more complicated apparatus in the human ear. 

Instead of a single rod, we find in the mammalian ear three distinct ossi- 
cles, called respectively the hammer, the anvil, and the stirrup. The three 
are connected together in a peculiar manner. 
The hammer, the first of the series, occupies 
such a position on the outer side of the tym- 
panum that its handle (sp to U, in Fig. 3) pro- 
jects from above downward as far as to the 
centre (U) of the membrana tympani, with 
which it is intimately united (see also Fig. 1). 
In the next place the upper limit of this mem- 
brane consists of a band of fibres, which holds 
the hammer very firmly at a point midway be- 
tween the end of the handle and the top of 
the head, and allows it to perform only limited 
rotary motions, inward and outward. The 

second ossicle, the anvil, grasps as it were the head of the hammer by means 
of a peculiar interlocking of their respective articular surfaces. 1 From the 



h- 




H 



~-~X$ 



Fig. 3.— Diagram showing the Rela. 
tions of the Hammer to the Membrana 
Tympani : H, head of hammer; U (um- 
bo), the tip of the handle of hammer, cor- 
responding to the centre of the mem- 
brane; sp, the short process of the 
hammer. 



1 Helmholtz, who was the first to describe the real nature of the malleo-incudal joint, 
compared it to " the joint used in certain watch-keys, where the handle cannot be 
turned in one direction without carrjdng the steel shell with it, while in the opposite 
direction it meets with only slight resistance." 



4 DIAGNOSIS AND TREATMENT OF 

body of the anvil two processes project, the one backward to articulate with 
the posterior wall of the cavity, the other downward to articulate with the 
head of the third ossicle, the stirrup. While the articulation between the 
hammer and the anvil is of such a nature as to admit of almost no play of 
the articular surfaces upon each other, that between the long process of the 
anvil (see Fig. 1) and the head of the stirrup, 1 on the contrary, admits of full 
play between the two surfaces. 

Finally, the articulation between the foot-plate of the stirrup and the 
margin of the oval opening, which leads to the labyrinth, consists simply of 
a band of elastic fibres that span the narrow space which separates the bor- 
der of the foot-plate from the margin of the window in which it fits. 

What part, then, does this apparatus play in the function of hearing, 
and what are the mechanical effects of its action upon the fluid of the laby- 
rinth ? Obviously, to transmit accurately to this fluid body the same im- 
pulses which the membrana tympani receives. The mechanism may be 
thus described : 

Let us suppose that a purely simple tone of one hundred vibrations 
per second is sounded within hearing distance. The air in the immediate 
vicinity of the membrana tympani will be alternately condensed and rare- 
fied one hundred times during the period of a second ; or, in other 
words, the membrane itself will vibrate inward and outward the same 
number of times. But, inasmuch as the handle of the hammer is, so to 
speak, an integral portion of the membrana tympani, it, too, will perform 
the same number of excursions inward and outward. In the next place, 
the firm union between the head of the hammer and the body of the anvil 
will oblige the latter to follow the direction communicated to the head of 
the hammer by the excursion of its handle. A glance at the figure (Fig. 
1) will show that on the anvil the direction of the motion imparted to it 
will vary according to the locality : thus, if the handle of the hammer be 
in the act of making an excursion inward, the top of the body of the anvil 
will be found moving in an outward and somewhat upward direction, while 
at the extremity of its long process (near the head of the stirrup) the 
motion will be chiefly upward, with somewhat of an inclination inward. 
The stirrup, whose head plays freely within the articular capsular ligament 
upon the end of this long process, will convert the impulse thus received 
into a motion, partly hinge-like and partly piston-like in its character. 

It is therefore the function of the chain of ossicles to transmit to the 
fluid of the labyrinth whatever impulses may be communicated to the mem- 
brana tympani by sonorous vibrations in the air of the external auditory 
canal. 2 

1 This articulation is not unlike the knee-joint, where the articular surfaces are 
separated by an infcerarticular cartilage (called ?neniscus, in the stapedo-incudal joint). 

9 This doctrine, which was first put forth by Edward Weber, in 1851, was confirmed 
experimentally by Politzer, in 1868, and afterward by other observers. 



DISEASES OF THE EAR. 

Whatever then may be the nature of these vibrations, it is evident, from 
the character of the attachments which hold the hammer in situ, that the 
only impulses which this ossicle is capable of transmitting are such as may 
be communicated to a single point in the handle, as, for instance, the tip. 
In the case, therefore, of a purely simple tone — by which is meant one that 
is perfectly free from all admixture of overtones — the point referred to 
would be subjected to a simple, pendulum-like motion. 1 In the case of a 

1 During the winter of 1869-70, I made a series of experiments for the purpose of 
determining accurately the behavior of the different ossicles, the drum-membrane, and 
the membrane of the round window, under the influence of somewhat violent sonorous 
impulses. I will give here a brief account of these experiments. 

Eleven human adult temporal bones were removed from the bodies as soon as pos- 
sible after death, and preserved in a very weak solution of spirits of wine. A portion 
of the cartilaginous external auditory canal was left attached to each temporal bone, 
sufficient to admit of the introduction of a suitable sound-conducting tube. The roof 
of the drum was then carefully chiselled away until a good view could be obtained of 
the greater part of the hammer and anvil, and of the head of the stirrup. The laby- 
rinth and all the connections of the membrane of the drum and ossicles, with the ex- 
ception of the ligamentum mallei superius, were left undisturbed. As sound -producing 
media, organ-pipes were found to answer the purpose best. To connect these with the 
ear in such a way that the vibrations within the pipe might be conveyed with the least 
possible loss to the air contained in the external auditory canal, the open end of the 
pipe was closed with a thin board cover, and a glass tube 17 ctm. long, and with a 
lumen of 14 mm. , was firmly inserted into an opening in the centre of the board. The 
free end of the glass tube had been previously drawn out so as to present a lumen of 
5 mm. This was made to fit tightly in the external ear by surrounding the end with 
sealing-wax. For light, an ordinary kerosene lamp was used, the rays from which 
were concentrated by means of a convex lens on the spot to be observed. This had 
been previously dried with the end of a heated wire, and then sprinkled with powdered 
starch. These fine masses of starch, when examined with a low power of the micro- 
scope (24 diam.), appeared as sharply defined luminous points, or, when set in rapid 
motion, as luminous lines. In the course of the experiments, however, it was ascer- 
tained that starch could be dispensed with, as the simple irregularity and moisture of 
the parts offered a sufficient number of luminous points for all purposes of observation. 

Measurements. — The average measurements obtained in the manner described above 
fihow that an impulse given to the centre of the drum-membrane is communicated 
from ossicle to ossicle with a loss in the following ratio : — 

Hammer = 4 
Anvil = 2 
Stirrup = 1 
In two instances where the membrane of the drum was caused to vibrate feebly, 
scarcely any loss took place in the transmission of the impulse from the hammer to 
the stirrup. If we take into consideration, moreover, that all these measurements may 
be looked upon as representing rather the maximal than the ordinary excursions of the 
ossicles, it may well be doubted whether during life the loss in transmission be not 
much smaller than that given above. 

Direction of luminous lines on different parts of the ossicles. — As observed from above, 
the luminous lines on the heads of the hammer and anvil appeared slightly divergent 
outward. This divergence was found to be the same on all the specimens. As ob- 



6 DIAGNOSIS AND TREATMENT OF 

complex tone, or of two or more tones produced simultaneously, it is not 
so easy to represent clearly to the mind's eye the movements which the 
point in question must execute. Prof. Alfred Mayer, of the Stevens Insti- 
tute of Technology (Hoboken, New Jersey), has devised an experiment 
which almost renders these movements visible to the eye. It was executed 
in the following manner : 

Placing a stretched membrane in a vertical position, and attaching fine 
threads of silk to its centre, Prof. Mayer put them moderately upon the 
stretch, and fastened them, each one to a tuning-fork (to one branch only) 
of different pitch. Upon sounding an organ-pipe (an instrument rich in 
overtones) on the other side of the membrane, he distinctly heard the 
tones of some of the forks. The moment the threads were cut, the tones 
ceased. After the threads had been reattached, the forks again vibrated 
audibly. When the organ-pipe was changed for one of a different pitch, 
it was observed that a different set of forks were excited to vibration. 

served from the side, in a direction at right angles to the long axis of the hammer, 
they presented the following appearance : On the hammer the luminous lines ap- 
peared to be arcs of circles whose common centre lay in the immediate neighborhood 
of the processus Folianus. On two of the specimens it was noticed that the luminous 
lines, measured at the very end of the handle of the hammer, were 0.43 mm. and 0.38 
mm., whilst those measured at the head were 0.31 mm.; in other words, that in these 
instances, at least, the axis of rotation did not pass through the middle of the ossicle, 
but somewhat above it. On the lower part of the long process of the anvil the lumi- 
nous lines seemed to be nearly or quite vertical, but on approaching the body of the 
bone they became more oblique. 

As observed from above, the luminous lines on the stirrup appeared in the majority 
of cases to be directed nearly, though not quite, at right angles to its base. In only 
two cases was it found possible to obtain a view of both arms of the stirrup at once. 
In one of these cases the luminous lines were directed at right angles to the base, while 
in the other they ran somewhat obliquely toward it. The inclination in all cases was 
toward the anterior extremity of the base. Viewed from the side, the luminous lines 
on the stirrup were in all instances directed obliquely upward and inward across the 
head and anterior arm. In one specimen the upper and inner wall of the vestibule was 
carefully chiselled away, so as to present an inner view of the base of the stirrup. 
When it was put in vibration the luminous lines on the upper border of the base meas- 
ured 0. 03 mm. and were vertical, but on the lower border there was not sufficient 
motion to admit of measurement. 

Fenestra Rotunda.— Enough of the lower wall of the drum-cavity was removed in 
one specimen to admit of a good view of the membrana tympani secundaria. The 
moment the organ-pipe was sounded the bright spot in the centre of the membrane 
lengthened out into a distinct luminous line of 0.04 mm. On the head of the stirrup, 
as seen from above, the luminous lines measured only 0.03 mm. The superficial area 
of the fenestra rotunda being smaller than that of the base of the stirrup, a greater 
excursion might rightly be expected from the membrane of the former. In the pres- 
ent case the membrane was observed obliquely from the side and not directly in pro- 
file, so to speak ; hence the measurement would represent only a portion of the true 
length of the excursion. The measurements on different parts of the ossicles, before 
and after breaking up the membrane of the round window, were the same. 



DISEASES OF THE EAR. 



While this experiment, then, furnishes us with a most valuable mean 3 
of analyzing sound, it also clearly demonstrates that a given point in a solid 
body can be made to perform, at one and the same instant of time, the vi- 
brations belonging to a number of tones of different pitch ; in the present 
instance these were the fundamental note of the organ-pipe, together with 
its overtones. This complex vibration has often been compared to the 
changes which take place on the surface of a body of water. Thus, for in- 
stance, in looking at the ocean, we often observe that the surface is thrown 
into undulations by long and heavy swells ; while upon them are numerous 
waves and smaller wavelets. Here, then, we see an illustration of the man- 
ner in which several kinds of waves may set in motion the same body of 
water at the same moment of time, without interfering with each other in 
any way. 

If we admit that the ossicles can vibrate in this manner in response to 
four or five tones, sounded simultaneously, there remains no serious obsta- 
cle to the belief that they can also vibrate in response to an almost indefi- 
nite number of tones. In listening to conversation, to music, and to sim- 
ple noises, our ossicula auditus are simply called upon to transmit at one 
and the same moment of time a varying number of impulses — for music, 
noises, and conversation, are all reducible to combinations of purely simple 
tones. 

In the last place, how is it possible for the terminal filaments of the 
auditory nerve to analyze these impulses of such varying rates of vibration ? 
Before I attempt to answer tins question, it will be necessary to take a 
glance at the anatomy of the last cavity mentioned above, — the labyrinth, — ■ 
and to inquire into the mechanical effects produced upon its contents by 
the piston-like motion which we have attributed to the stirrup. 

If we take a temporal bone, either in its natural condition or in the dried 
state, and endeavor by simple inspection to get some idea of the form, size, 
and relations of the labyrinth, we shall fail completely. There are only two 
points where we can get a glimpse of this portion of the ear, and these are 
at the two openings mentioned above as being situated in the inner wall of 
the middle cavity or tympanum. At all other points the various channels 
and cavities of the labyrinth are deeply imbedded in the substance of the 
petrous portion of the bone. It is only by the aid of the hammer, the 
chisel, and the knife, that we can obtain the thin shell of bone which repre- 
sents, as it were, the mold of the contained cavities. In this way we find 
that the labyrinth — we are speaking now only of its osseous boundaries — 
consists of a central cavity, not more than two lines in diameter, from one 
side of which spring, like arches, the three semicircular canals, while from 
the other side a canal leads into the snail-shaped body called the cochlea. 
In their natural state these bony cavities are filled with membranous struc- 
tures and fluid. Thus, for example, the central cavity — or vestibule, as it is 
technically called — contains two distinct membranous sacs (see Fig. £), 



8 



DIAGNOSIS AND TREATMENT OF 



which together do not quite take up the entire space of the cavity, but leave 
room, in the immediate vicinity of the foot-plate of the stirrup, for a cer- 
tain amount of free fluid (Henle). The smaller of the two sacs, the saccule 
(S, Fig. 4), communicates with one of the membranous tubes of the cochlea, 
the ductus cochlearis. The larger one, the utricle ( U, Fig. 4), is continuous 
with the membranous tubes, which partially fill the semicircular canals : in 
fact, the two constitute an intercommunicating system of cavities, contain- 
ing fluid, and bounded by membranous walls, so that pressure made upon 
the utricle will result in an increase of tension in the walls of the membra- 
nous semicircular canals. 

If we uncoil the cochlea^and so convert it into a single straight bony 
tube, we shall find that its shape resembles that of an elongated truncated 
cone, whose base corresponds to the vestibular end of the cochlea, while 




Fig. 4.— Diagram of the Labyrinth : V, the vestibule, or central cavity, which is nearly filled by 
the utricle (U) and the saccule (S). Near the foot-plate of the stirrup, there is free fluid, which also ex- 
tends up into the scala vestibuli (S V) of the cochlea. D C, the ductus cochlearis, which communicatee by 
a slender membranous channel (canalis reuniens) with the saccule. Between the cochleal duct and the 
scala tympani (S T) is a narrow white band, representing the membrana basilaris, At the extreme tym- 
panic end of the scala tympani, a faint white line indicates the position of the membrana tympani secun- 
daria. A, .4, A, ampullae of the membranous semicircular canals, which, in these regions, fit pretty closely 
their surrounding bony walls. 

the smaller end would represent the cupola, or highest point of the cochlea 
in its natural position. There are certain membranous l septa which divide 
this single conical tube into three distinct and entirely separate chan- 
nels, one communicating directly with the vestibule, while the other 
two are entirely shut off from any communication with it. In the first 



In one instance partly membranous and partly osseous. 



DISEASES OF THE EATC. 



place, a sort of diaphragm divides the tube horizontally into an upper and 
and a lower passage, each of nearly equal size. The upper one communi- 
cates by a broad mouth with the cavity of the vestibule, and for this reason 
has been named the vestibular channel or scala vesti- 
buli ; the lower follows its course toward the tym- 
panum, but at the round window is shut off from 
it by a thin membrane — the membrana tympani secun- 
daria. This lower channel is called the scala tympani. 
(Follow Fig. 4 for all these points.) A second dia- 
phragm, which runs at an angle of 45° with the first 
(see Fig. 6), divides the upper channel into the scala 
vestibuli proper and the ductus cochlearis. This 
last-named duct or channel is in reality a closed sac ; 
its shape being that of an elongated truncated cone, 
whose base occupies the cupola, while the smaller 
end lies at the very entrance to the cochlea in the 
vestibule. The ductus cochlearis may therefore be 
described as a body of fluid imprisoned within mem- 
branous walls, and containing certain peculiar struc- 
tures, which will be mentioned in detail hereafter ; 
and it may also be described as playing the part of 
a diaphragm between the fluid of the scala vestibuli 
and that of the scala tympani. 

We have now completed our hasty sketch of the 
labyrinth as a system of channels and closed sacs 
containing fluid, and it still remains for us to 
speak of the peculiar structures contained within the 
ductus cochlearis, — structures which have been shown 
to stand in direct communication with filaments of 
the auditory nerve, and which must therefore be con- 
sidered as constituting the real terminal apparatus of 
hearing, in the same sense as the retina is held to be 
the terminal organ of sight. 

In the first place, the diaphragm, mentioned above 
as dividing the entire cochleal tube into an upper 
and a lower passage, will be found on microscopic 
examination to consist partly of bone and partly of 
membrane. The membranous portion of this dia- 
phragm — if it were possible to dissect it out entire 
and spread it out before us — would be found to have a shape something 
like that given to it in Fig. 5. The small end V represents the com- 
mencement of the membrane near the round window, and the large end 
c its termination in the cupola. If we remove all the superimposed struc- 
tures and examine this membrane under the microscope, we shall find it to 



Fig. 5.— Diagram of the 
Membrana Baeilaris : F, ita 
vestibular end ; c.that in the 
cupola. 



10 



DIAGNOSIS AND TREATMENT OF 



consist of an almost countless number of rods, separated one from another 
by a glue substance of but slight adhesive power. If we leave the super- 
imposed structures in situ, and make a transverse section through the mem- 




Fig. 6. — Transverse Section of a Cochleal Whorl. On the right, embedded in the substance of the bone, 
is a group of ganglion cells, through which the fibres of the auditory nerve pass before entering the lamina 
spiralis ossea. This latter is represented in the figure as a broad septum, separating the scala vestibuli {S 
V) from the scala tympani (S T), and containing a canal for the passage of the auditory nerve-fibres. 
In the canal these fibres still possess a medullary sheath, but, on emerging therefrom into the ductus coch- 
lears (Z> C), they break up into naked axis-cylinders and terminate (as white threads in the drawing) in 
the single inner and four outer hearing cells. The cilia of the four outer hearing-cells may be seen pro- 
jecting through the lamina reticularis ; those of the single inner cell (invisible in the drawing) project 
above the head of the inner pillar of Corti. The lamina reticularis is drawn as an horizontal projection 
(outward) of the upper portion of the head of the outer pillars of Corti. Underneath, these pillars 
rest upon the membrana basilaris, which terminates on the outer side in the ligamentum spirale (repre- 
sented in the figure as a pale, crescent-shaped pad of connective tissue, fitting accurately to the surround- 
ing shell of bone). The cilia of the hearing-cells come into contact above with the membrana tectoria or 
CortVs membrane, which springs from the upper side of the lamina spiralis ossea, near its free extremity, 
and terminates, by a thin extension, in the ligamentum spirale. Reissner's membrane is represented as a 
straight band, which stretches from the bony wall above, down to the upper side of the lamina spiralis os- 
sea, and separates the ductus cochlearis from the scala vestibuli. 

brane, we shall find that it carries upon its upper surface the following pe- 
culiar anatomical elements (see Fig. 6). 

1. A nearly central ' arch, composed of two pillars, called respectively 
the inner and outer pillars of Corti. The shafts of these pilars are compara- 



1 The arch occupies such a position that the bases of the outer pillars stand very 
nearly in the centre or median line of the membrane. It is a significant fact that the 
outer rows of hearing-cells also occupy the central portion of the membrane, or that 
part which performs the greatest amplitude of excursion. 



DISEASES OF THE EAR. 11 

tively slender, but their bases and their heads are broad. The points to 
which attention should be called in the anatomy of these pillars, are their 
great strength and stiffness as compared with the other structures to be 
found in the ductus cochlearis ; the constantly increasing distance between 
the bases of the inner and outer pillars, as you go from the vestibule to the 
cupola ; and, finally, the rounded character of the articular surfaces, where 
the heads of the inner and outer pillars come together — a peculiarity of con- 
nection which would indicate that a certain amount of play would be possi- 
ble between the opposite heads of the pillars, in case the vibrations of the 
entire apparatus take place in a vertical plane. 

2. A peculiar fenestrated membrane, the lamina reticularis, which ex- 
tends in a horizontal direction some little distance outward from the heads 
of the pillars of Corti, to which it seems to be in some way attached. 

3. Five rows of ciliated cells, four on the outer side of the arch, and 
one on the inner side, close to the inner pillars of Corti. The four outer 
rows insert their heads into the openings of the fenestrated lamina reticu- 
laris in such a manner that the cilia stand up like bunches of hair at regu- 
lar intervals along the surface of the membrane. Bundles of primitive 
nerve-fibrils from the cochleal branch of the auditory nerve have been 
traced to all five rows of ciliated cells, but to no other structures in the 
ductus cochlearis. Hence the name of hearing-cells, which has very appro- 
priately been awarded to these evidently the most important elements in 
the apparatus we are endeavoring to describe. 

4 Simple epithelial cells, destined apparently to serve as a support to 
the lamina reticularis and to the outer and inner rows of hearing-cells. 

5. A peculiar membranous structure, which starts from the upper side 
of the hooked shaped process of the lamina spiralis ossea and extends out- 
ward over the lamina reticularis. This membrane is mucoid (or doughy) 
in consistency, and, from the fact that it lies like a gelatinous veil over, and 
perhaps in contact with, the cilia of th~ hearing-cells, it is called the mem- 
brana tectoria 1 or covering membrane. As far as to the outer limit of the 
hearing-cells, this membrane retains its thick, doughy consistency, but be- 
yond this region it is continued in the form of a very thin lamina to its 
line of insertion in the ligamentum spirale. 

It is not necessary to a clear understanding of the mechanism of the final 
act of healing, that we should enter, any more fully than we have done, into 
the minute anatomy of the ductus cochlearis. What remains for us to do is 
to follow out, step by step, the mechanical effects upon the various labyrin- 
thine structures of the piston-like vibrations of the stirrup ; for it was here 
that we left off in our efforts to trace the effects of sound upon the apparatus 
of hearing. 

The theory which is universally accepted by physiologists in explanation 

1 Also membrane of Corti. 



12 DIAGNOSIS AND TKEATMENT OF 

of tins point is the one given by Prof. Helmholtz, and called, in honor of 
that distinguished physicist, "the Hemholtz theory of hearing." ' The es- 
sential points in it are these : the component fibres of the membrana 
basilaris (Fig. 5) are to be considered in very much the same light as sepa- 
rate strings, which by a process of loading — that is, weighing them down 
with the pillars of Corti, the hearing-cells, etc. — have been tuned so as to 
vibrate in sympathy with all the appreciable tones, from the highest to the 
lowest. 2 In fact, for every half-tone of our present musical scale there must 
be in the cochlea at least thirty-three strings to represent all its possible 
shades. When the stirrup, for instance, vibrates one hundred times in the 
second, it must excite to action that particular string, or group of strings, 
which is tuned to vibrate one hundred times per second. The vibration thus 
caused makes an impression upon the nerve supplying the vibrating part, and 
this in turn produces in the brain the sensation of sound. The damping of 
the vibrations, at the instant the irritation which produced them ceases, is 
attributed partly to the presence of a fluid medium, and partly to the fact 
that the vibrating structures proper (the strings of the membrana basilaris 
and the pillars of Corti) are pressed upon by cell-bodies which are not 
adapted for vibration. 

The vertical vibration of the basilar membrane is distinctly recognized 
in this theory ; but, in the preliminary description of the anatomy of the 
cochlea, mention is made of the existence of a small opening (helicotrema) 
in the cupola, through which a communication is established between the 
scala vestibuli and the scala tympani. According to KoUiker and Eeichert, 
the blind sac of the ductus cochlearis entirely fills the cupola (the vestibular 
half of it). This statement would seem, then, either to throw doubt upon 
the existence of such an opening, or to make it a channel of communication 
between the ductus cochlearis (instead of the scala vestibuli) and the scala 
tympani. The latter supposition, however, involving as it necessarily does 
a certain degree of longitudinal current in the fluid of the ductus cochlearis, 
cannot for a moment be entertained, as it would utterly overthrow any the- 
ory based upon the sympathetic vibration of the fibres of Corti's organ. 
On the other hand, if the blind termination of the ductus cochlearis does 
not entirely fill the cupola — as some authorities maintain — but leaves room 
for the fluid of the scala vestibuli to pass through a small opening in the 
septum into the scala tympani, the theory of a vertical motion for the 
membrana basilaris is still tenable, as the existence of the helicotrema will 
simply serve to diminish the force of the vertical motion, but not to annul 
it. My own investigations, so far as they go, favor the view that no com- 
munication exists between the two scalse in the immediate vicinity of the 

1 See his work entitled Die Lehre von den Tonempfindungen, Braunschweig, 1870. 

2 The highest tones corresponding to the short strings near the vestibule, the lowest 
to the long ones in the cupola. 



DISEASES OF THE EAR. 13 

cupola, unless the opening, spoken of so vaguely by the authors, be micro- 
scopic in size. ' 

In the light of the histological discoveries made since the time when 
Helmholtz published his " Tonempfindungen " (1870), we would, with all 
due reserve, venture upon the following explanation of the mechanism of 
hearing in the cochlea : 

We have described the labyrinth as a closed cavity, having but two chan- 
nels of approach — the round and the oval windows — one of which is filled up 
tightly by the foot-plate of the stirrup. Since, according to physical laws, 
the fluid contents of the labyrinth cannot be supposed to undergo diminu- 
tion in bulk, under the pressure made by the foot-plate of the stirrup, we 
must assume — what has now been proved by direct observation — that the 
elastic membrane of the round window affords the required yielding-point 
for this displacement. 3 

The first body to receive the impulse of the stirrup is the free mass of 
fluid which fills those portions of the vestibule and the scala vestibuli, 
which are not occupied by membranous sacs. Without stopping here to 
discuss the effects of the stapedial 3 impulse upon the utriculus and serai- 
circular canals, let us proceed at once to the consideration of the effects 
which this impulse will produce upon the cochlear structures. 

In the first place a moment's thought will convince us that, in estimating 
the effects of the stapedial impulse upon the ductus cochlearis, we may to- 
tally disregard the sacculus and the canalis reuniens.* The uniform pres- 
sure of the fluid upon all sides of these last-named cavities will effectually 
prevent anything like a current from the ductus cochlearis to the sacculus, 
or the reverse, through the canalis reuniens. The ductus cochlearis — that 



1 To satisfy myself, if possible, on this point, Ijremoved the cochleae entire from 
the temporal bones of an infant, and softened them in a solution of chromic acid and 
hydrochloric acid (not more than five per cent, of each). When the earthy materials 
had been entirely removed from the bone, I placed the specimens in ordinary rlcohol 
for a few hours, and with the razor divided them each into two unequal parts, the plane 
of section being at right angles to the base of the cochlea. In one of the cochleae, the 
section passed so close to the bottom of the cul-de-sac of the cupola, that it was difficult 
to determine anything satisfactory with regard to the opening in question . In the other 
it was a comparatively easy matter, with an ordinary magnifying-glass, and after blow- 
ing out the free alcohol, to survey both the vestibular and tympanic surfaces of the sep- 
tum, which in the cupola divides the two channels from each other. No trace what- 
ever of any communication between the two passages could be detected. 

The results of a single examination like this cannot, of course, be considered as 
sufficient to overthrow the statements of the anatomists. Nevertheless, the lack of 
definiteness in their descriptions of this opening (see Henle's Anatomy and "Waldeyer's 
article on the Labyrinth in Strieker's Histology), taken in connection with its apparent 
absence in this one case, should lead to new investigations on this point. 

* This statement will be slightly modified farther on. 

3 Stapes — a stirrup. 

4 The little canal (Fig. 4) which unites the sacculus and the ductus cochlearis. 



14 DIAGNOSIS AND TREATMENT OF 

is to say, the upper and inner wall of it, or Reissrier's membrane — is there- 
fore subjected to a uniformly distributed pressure from above downward by 
the centrifugal (if I may so use the term) force of the fluid of the scala ves- 
tibuli. As it yields beneath this force, the incompressible body of fluid 
which fills the ductus cochlearis must in turn find its yielding-point in the 
entire membrana basilaris ; for this and Eeissner's membrane are the only 
two portions of the wall of the duct which are membranous, and therefore 
capable of yielding. Finally, the displacement caused in the contents of the 
scala tympani, by the depression of the entire membrana basilaris, is pro- 
vided for by the presence of an elastic membrane (membrana tympani secun- 
daria) at the larger end of this channel. 

This brings us, then, face to face with the fact that the entire membrana 
basilaris (including high and low notes alike) is obliged to perform all the 
excursions which may be communicated to the stirrup or the membrana 
tympani by sonorous vibrations ; or, to speak more minutely, with every 
tone sounded, every " organ of Corti " x must perform the excursions which 
belong to that particular tone. But if that be true, it will be asked, why 
should not all the nerve-filaments send communications to the brain ; or, in 
other words, why should we not hear all the notes of the scale whenever any 
one of them happens to be sounded ? This is our answer, and we might 
add that it has been suggested to us by the peculiar relations of the mem- 
brana tectoria to the hearing-cells, and by the passing remark of Waldeyer 
(in the article referred to above) that " no portion of the labyrinth could be 
better adapted, by reason of its anatomical construction and position, to 
perform this function [that of a damper] than the membrana tectoria." 

Although it be true that, with every note sounded, all the organs of 
Corti must perform the excursions belonging to that note, yet it must be 
remembered that the semi-gelatinous membrana tectoria, which rests upon 
the cilia of the hearing-cells, will likewise be obliged to perform these same 
excursions. Over one particular region, however, of the membrana basi- 
laris, this will not be the case, namely, in that portion where the thirty or 
more basilaris fibres are tuned to vibrate in sympathy with the note sound- 
ed. At this point the vibrations will be of sufficient vigor to throw off the 
membrana tectoria. So long, then, as that particular note is sounded, the 
cilia of the hearing-cells, in the region referred to, will receive a succession 
of taps from the membrana tectoria, or, to speak more strictly, will strike 
against this membrane. These blows constitute the true irritation of the 
auditory nerve. Wherever the blows do not take place, although the audi- 
tory nerve-filaments may be agitated in a direction at right angles to their 
length, there no sensations of sound will fee communicated to the brain. 

Still, another theory may be put forward in explanation of the mechan- 

1 The term ' ' organ of Corti " is used to designate the entire group of structures 
built upon the membrana basilaris. 



DISEASES OF THE EAR. 



15 



ism of the membrana tectoria. This membrane, in the natural relations of 
these parts, may not lie stretched out like a semi-gelatinous covering over, 
and in contact with, the cilia of the hearing-cells. It may, instead, be 
stretched like a canopy, a very short distance above them, — so short a 
distance, in fact, that, when any given group of organs of Corti is excited 
to sympathetic vibration, the cilia of the hearing-cells belonging to that 
group will strike against it, and so will experience the irritation necessaiy 
to the perception of sound. Tins theory does away with the necessity of a 




Fig. 7. — Transverse Section of Semicircular Canal, 
semicircular canal. (For further details, sea the text.) 



(Copied from Rudinger.) IT S C, membranous 



damper, but calls for a semi-soft, tense membrane (like that of the mem- 
brana tectoria) against which the cilia may strike without danger of being 
injured by the blow. 

Before leaving the subject, we should like to venture a suggestion as to 
the function of the semicircular canals. 

As is well known, the doctrine is almost universally upheld, that these 
canals contain organs which govern the function of equilibrium (Flourens's 
theory). About eight years ago Arthur Boettcher, 1 of Dorpat, demonstrated 

1 Dorpater med. Zeitschrift, Vol. III., Part II., 1872. 



16 DIAGNOSIS AND TREATMENT. 

by experiments upon living animals that this theory is probably incorrect 
(See Chapter XL). He proposed no new theory, but opened the way for 
others to do so if they wished. 

The first thing that attracts our attention in the anatomy of these or- 
gans is the peculiar relation of the membranous to the bony canals, the 
former occupying scarcely a third of the calibre of the latter. Then, in 
the next place, the space between the membranous canal and the bony walls 
is filled, not with free fluid, as is the case, for example, in the cochlea, but 
with a reticulated connective tissue, rich in blood-vessels and made up of 
large meshes containing fluid. In the vicinity of the mouths of these canals, 
however, it should be noticed that the membranous tubes hug the bone 
more closely (see Fig. 4). If we examine the mode of construction of the 
membranous canals, we find that the outer elastic wall (see Fig. 7) is lined 
with a sort of mucous membrane whose free surface undulates or is thrown 
into mounds, and carries a lining of ordinary pavement epithelium. An- 
other point worthy of notice is the absence of the undulations or mounds 
on that side of the canal which lies next to the bone — the side where dila- 
tation cannot take place. These anatomical relations and the absence of 
nerves are certainly suggestive of the thought that the function of these 
canals must be a mechanical one. Is it not their function, we would ask, 
to protect the ductus cochlearis and the organs of Corti from injury in cases 
where the stirrup is driven too violently into the oval window ? Any pres- 
sure made upon the utriculus can only find a yielding point in the elastic 
walls of the membranous semicircular canals ; and, furthermore, if the latter 
were lined with a smooth instead of an undulating epithelial surface, their 
distention would be followed by a rupture of the epithelial lining. 1 Any 
sudden and loud noise, like the report of a cannon or a peal of thunder, 
would be likely to injure the cochlear structures, were not some provision 
made in the labyrinth for extraordinary events of this kind. As we have 
shown, the semicircular canals are not only admirably fitted to serve in the 
capacity of safety-valves, but their entire mode of construction, especially 
the absence of all nervous structures (except in the ampullae), would seem 
to exclude them from any higher office in the mechanism of hearing. 

The suggestion of a recent writer (Hensen), that their function is that 
of secreting the labyrinthine fluid, has against it the fact that the epithelial 
cells lining the canals are of the pavement and not of the cylindrical or 
glandular variety. 

1 To establish this theory, it will be necessary to ascertain the circulation of blood in 
these parts, for the anastomosis of the veins surrounding the membranous canal with 
the veins of the bony walls is apparently essential to it. 






CHAPTEK II. 
EXAMINATION OF THE PATIENT. 

Tests of the Heaktng-Power. 



As a large proportion of the diseases of the ear are associated with im- 
pairment of the function of hearing, we constantly find it desirable to meas- 
ure the degree of this impairment. Furthermore, this part of our exami- 
nation of the case is usually carried out before the condition of the ear has 
been disturbed by the manipulations incident to the further examination 
of the patient. It seems proper, therefore, to consider this branch of our 
subject first, and to describe afterward the more strictly instrumental 
methods of examining the ear. 

There are two tests in common use for estimating the acuteness of a 
person's hearing-power. These are, the ticking of a watch and spoken or 
whispered words or sentences. Both of these tests are unsatisfactory in 
very many cases. Thus, for example, one patient will distinguish the tick- 
ing of a watch when held at a certain distance from the ear, and yet he will 
not be able to understand ordinary conversation. Another will hear con- 
versation with perfect ease and yet be unable to distinguish the ticking of 
a watch except when it is pressed against his ear. Again, a patient will 
at one time, e.g., during a subacute inflammation of the middle ear, hear 
the ticking of a watch only a very short distance, perhaps an inch or two, 
and will experience considerable difficulty in understanding spoken words. 
As the inflammation subsides, and the fluid exudation undergoes absorp- 
tion, he will experience a very decided improvement in his power to under- 
stand conversation, but little or no improvement in his power to distin- 
guish the ticking of the watch. On the. other hand, an appreciable im- 
provement in the power to distinguish the ticking of a watch is commonly 
associated with some (not a corresponding) degree of improvement in the 
power to hear spoken words. This last experience, coupled with the great 
convenience of the watch as a source of sound of uniform intensity, has led 
to its being generally used as a test, notwithstanding all its imperfections. 

Theoretically it would seem as if the only proper test must be that by 
means of spoken or whispered words or sentences. Thus, for example, 
when a person, who is suffering from deafness, applies to a physician for 
2 



18 DIAGNOSIS AND TREATMENT OF 

relief, his principal object is, not merely to regain the power of hearing 
certain delicate sounds (like the ticking of a watch), or of clearly distin- 
guishing each individual tone in the musical scale, from the lowest to the 
highest, but rather to secure an improvement in, or a restoration of, the 
power to understand spoken language. Very few physicians, however, 
have office accommodations of sufficient extent to render such a mode of 
testing the hearing possible in any but the aggravated forms of deafness. 
In the next place, it is difficult to use the voice at the same pitch and with 
the same intensity on all occasions. Finally, certain words are distin- 
guished by the ear much more readily than others. Take, as examples, 
such words as " distinguished " and " difficulty," and it will be found that 
a patient who can readily hear words like "alarm," "rider," "create," at a 
given distance, will fail utterly, at the same distance, to distinguish cor- 
rectly these less resonant ones. In other words, we may test our patient's 
hearing at different times by means of spoken words, and obtain very dif- 
ferent results each time, according to the character of the words used. If 
the test were trustworthy, the conclusions would be that our patient had 
improved or lost ground, according to the increase or diminution in the 
apparent hearing distance. The truth, however, might be that no change 
whatever had taken place in his hearing-power. Attempts have been made 
to remove these objections by preparing a series of test-sentences of uni- 
form value as regards the prevalence of vowel-sounds. It is undoubtedly 
possible to prepare, in a rough sort of manner, such a series of test-sen- 
tences ; but unfortunately the remaining objections to the employment of 
the voice as a means of testing the hearing, viz., inadequate size of room, 
difficulty of excluding outside noises, impossibility of always using the 
same pitch, loudness, and distinctness of voice, are still so serious, that in 
our large cities, at least, this mode of testing the hearing is not likely ever 
to be used to any great extent. In many cases, therefore, we are compelled 
to base our judgment with regard to the condition of the hearing, upon the 
patient's own statements or those of his friends. This is especially true in 
the case of young children, whose answers, when the watch is being used 
as a test, are generally untrustworthy. An observing mother or nurse, 
however, will be very likely to discover the first evidences of improvement 
in the child's hearing, and upon her statements we may safely base our 
judgment with regard to the progress of the case in this respect. 

In the employment of both the tests mentioned, it will be found desir- 
able to observe certain precautions. Thus, for example, if we wish to test 
the hearing of one ear by means of spoken words, it is absolutely necessary 
that the other ear should be closed quite firmly. The patient should also 
sit in such a position that the physician's voice may be thrown directly 
against the ear which remains open, i.e., at right angles to that side of the 
head. If we desire to test the hearing-power of both ears, the patient 
should sit facing us, but with both his eyes closed. Deaf people sometimes 






DISEASES OF THE EAR. 19 

possess the power of "reading the lips" to such a remarkable degree that 
the test can hardly be considered a fair one unless the patient has kept his 
eyes closed. It is also not sufficient for the patient to answer that he has 
understood what was said to him ; he should be required to repeat the exact 
words spoken by the physician. 

In testing with the watch, it is not necessary to close the ear which is 
not being examined, as the ticking of an ordinary watch, or the click of 
Politzer's acoumeter, is too feeble a sound to reach the opposite ear through 
the head and intervening mass of air. When the watch is pressed against 
the ear, it is quite possible that the sound of its ticking may reach the other 
ear. At the same time I do not remember ever to have met with such an 
instance, and yet my watch ticks with such vigor that in a quiet room it 
can usually be heard at a distance of twelve feet. In carrying out the 
test it is better to bring the watch nearer and nearer to the patient's ear, 
until he says that he can hear it, than to remove it farther and farther away, 
until he says that he can no longer distinguish the ticking. 

Thus far, the ticking of a watch has been found to afford the best prac- 
tical means of testing the capacity of the ear for distinguishing delicate 
sounds. If Politzer's acoumeter could be surrounded by a solid metallic 
case, and if some better contrivance could be devised for producing the 
blows, the instrument might come into general use as a substitute for the 
watch. If measurements of the hearing distance could be universally made 
with some standard source of sound of fixed intensity, the necessity for 
recording our measurements in fractions (Prout's method) w r ould be done 
away with ; it would be sufficient to merely state the actual distance meas- 
ured, and every physician who was familiar with such tests would appreci- 
ate at once the degree of impairment of the hearing reported. Politzer's 
idea in producing the " acoumeter " undoubtedly was to furnish such a 
standard test. Unfortunately, in its present shape this instrument costs 
too much, is likely to get out of order too easily, and cannot be manipu- 
lated with comfort. On the other hand, its click can easily be heard a dis- 
tance of thirty feet in a quiet room, and the instrument can therefore be 
used in certain cases where the watch would fail to show even a fair degree 
of improvement in the hearing. 

So long as we continue to use the watch as a means of testing the hear- 
ing, the fractional method of recording the hearing distance is undoubtedly 
the best. This method, which was first suggested by Dr. Prout, of Brook- 
lyn, N. Y., requires that the numerator of the fraction should represent the 
distance at which the watch is heard by the person whose hearing is being 
tested, w T hile the denominator indicates the average distance at which a 
reasonable number of persons with good hearing can distinguish the tick- 
ing of the same watch. It is only when we have occasion to report a case 
that it is desirable to designate the hearing distances in fractional terms. 
In our own private records the actual distances are alone sufficient. 



20 DIAGNOSIS AND TREATMENT OF 



Instruments and Methods of Examination. 

In the examination and treatment of patients suffering from ear disease 
we are in very great measure dependent for success upon the instruments 
■which we use. If they are of clumsy or faulty construction, we are not 
likely to obtain all the information that we have a right to expect from 
fcheir use, or our patients are subjected to unnecessary discomfort or even 
pain, which properly constructed instruments would not inflict. Two or 
three years ago I had occasion to inspect the ear-instruments kept for sale 
by several of our leading instrument-makers, and was amazed to find in 
how many important particulars these instruments were defective. Many 
were in fact entirely useless ; and yet I was assured that these were the 
same as those which they had sold for several years past and were still con- 
stantly selling to physicians who asked to be supplied with the instruments 
usually required in the examination and treatment of the ear. In view of 
this fact I think I may very properly devote considerable space to the con- 
sideration of the subject of instruments. 

Some individuals possess external auditory canals so large and straight 
that the physician can easily obtain a view of the drum-membrane without 
the assistance of instruments of any kind. In the great majority of adults, 
however, and in all young children, two kinds of instruments are required 
for the attainment of this object : one to push aside the soft walls of the 
orifice and render the canal approximately straight ; the other to illuminate 
the parts thus rendered accessible. Different forms of specula supply the 
first want, and concave reflectors the second. 

Ear-Specula. 

There are practically four kinds of ear-specula now in general use, and 
they may all be purchased in three different materials : hard rubber, German 
silver, and coin silver. If nitric acid or nitrate of silver is to be applied to 
some particular part of the drum-membrane or auditory canal, a hard-rub- 
ber speculum will be found a very useful instrument, as these corrosive 
substances destroy the brightness of the inner surface of the metal specula. 
Under ordinary circumstances, however, they will be found decidedly in- 
ferior to the metal instruments, and especially to those made of coin silver. 
The dark inner surface of the rubber speculum absorbs much of the light 
which in the metal instrument is reflected down upon the deeper parts of 
the auditory canal. So, far, therefore, as the choice of materials is con- 
cerned, the gain in the degree of illumination decides the question in favor 
of the coin silver. 

Of the four different forms of specula usually to be found in the shops, 
two seem to me to be unpractical, and well adapted in inexperienced hands 






DISEASES OF THE EAK. 



21 



to cause pain. I refer to the instruments which bear the names of Toynbee 
and Von Troeltsch. Of the remaining two, those of Wilde and Gruber, I 
may say that, while I employ both, I think the preference should be given 
to the short conical Wilde's specula. There are very few cases in which 
the advantages claimed for Gruber's specula are likely to be appreciated. 
These advantages are : first, with a meatus of a given size, a larger field of 
view can be obtained than with a conical instrument ; second, the broad 
external mouth of the speculum leaves more room for instrumental manip- 
ulations than is afforded by any other form of speculum. These two ad- 
vantages must be conceded to Gruber's instrument, whose oval shape cor- 
responds with that of the average adult meatus ; but, as I have just said, it 
is not often the case that we miss these advantages in using the conical 
Wilde's specula. On the other hand, the latter instruments possess certain 
advantages which may be observed in every-day practice and which are 
likely to make them permanently the most popular of the different aural 
specula. In the first place, the conical instruments can be kept polished 
on the inside much more easily than those of the Gruber pattern. This is 
an important advantage, which the physician will appreciate just in propor- 
tion to the degree of use which he makes of the instrument. A second ad- 
vantage is to be found in the good purpose which the instrument serves as 
a dilator. In cases of cedematous swelling of the outer portion of the meatus 
it is sometimes astonishing to what an extent the calibre of the canal may 
be enlarged by the judicious employment of these specula. Beginning with 
the smallest size of instrument, and pushing it inward with a rotatory 
movement, we may introduce one after another of the different sizes until 
we are able to employ one with an aperture of even five millimetres. The 
oval shape of Gruber's speculum renders its use as a dilator less easy to the 
physician, and decidedly more painful to the patient. 

The practitioner should possess at least three sizes of ear-specula. The 
smallest size should have an aperture of not less than three and a half milli- 
metres. An expert, it is true, can use one with an aperture of only three 
millimetres, but the task of seeing anything through it is far from easy. 
On the other hand, it is rare that he will find any advantage from using an 
instrument with an aperture of more than seven millimetres. With regard 
to the proper length of an ear-speculum, I should place it at from three 
and a quarter to three and a half centimetres. In selecting a set of specula, 
Inference should be given to those which have the thinnest walls. The 
great majority of ear-specula sold in the shops are of too solid construction. 
The thick walls of the instrument greatly diminish its internal calibre, 
and thus narrow the field of vision attainable with a meatus of a given size. 
It is safe to say that the thickness of the walls of the average ear-speculum 
might be diminished one-half without rendering the instrument unduly 
liable to bend. The blackening of the inner surface of the speculum simply 
diminishes the degree of illumination obtainable with a given source of 



22 DIAGNOSIS AND TKEATMENT OF 

light. Polished specula are therefore preferable— certainly for purposes of 
diagnosis. 

Bejiectors. 

Two kinds of contrivances are generally used for the purpose of reflect- 
ing light into the external auditory canal, viz., the hand-mirror and the fore- 
head-mirror. So far as the mirror itself is concerned, these two are one and 
the same thing. In practice it has been found that the best illumination is 
obtained with a concave mirror of circular form, whose focal distance may 
vary from twelve to thirty centimetres, according to the visual power of 
the observer. The majority of men will find a focal distance of about twenty 
centimetres the best adapted to their purposes. With regard to the size of 
the mirror, it may be said that one having a diameter of seven centimetres 
is as large as the observer can conveniently handle. Almost all the mirrors 
offered for sale have a central aperture, or unsilvered spot, through which 
the observer can see the parts illuminated directly in the focal line. If the 
hand-mirror be used, it is probably better to place the eye in the focal line 
than to look over the edge of the mirror. At the present day, however, all 
students of otology who are not near-sighted should be taught to use only 
the forehead-mirror. While at first it may be found more difficult to man- 
ipulate than the hand-mirror, its advantages over the latter are so great as 
to more than compensate for the difficulties encountered in learning how 
to use it properly. These difficulties once overcome, the physician no 
longer requires an assistant, but has both hands free for the various man- 
ipulations which are required in even the simplest case. The forehead-mir- 
rors usually sold in the shops, and commonly pictured in the text-books, are 
very poorly adapted to the wants of an aural surgeon ; some of them are in 
fact absolutely useless for his purposes. If we examine these instruments 
carefully, we shall find that they are fundamentally wrong in two respects : 
first, no space — or insufficient space — is left between the forehead-plate 
and the upper edge of the mirror, thus rendering it either difficult or im- 
possible for the observer to see the ear ; second, the ball and socket joint, 
by which the mirror is attached to the forehead-plate, allows the former to 
be rotated to such a limited extent, both from side to side and from before 
backward, that the observer will often find himself unable to use the source 
of light that may happen to be available, unless he changes its position or 
that of the patient, or both. If the forehead-mirror, however, be properly 
constructed, the observer will find comparatively little difficulty in placing 
himself in such a position that he can utilize almost any source of light that 
he may find at hand. The accompanying cut (Fig. 8) gives a correct re- 
presentation of a forehead-mirror well adapted to the wants of the aural 
surgeon. The details of construction are as follows : The forehead-plate is 
made of hard rubber, 9£ ctm. long, 2£ ctm. broad at the broadest part, a 
trifle more than a millimetre in thickness, and curved flatwise, so as to He 



DISEASES OF THE EAR. 



23 




Fig. 8.— Forehead-mirror. (Half the natural size.) 



at all points in firm contact with the forehead. This concave side should 
not be padded, partly for reasons of cleanliness, and chiefly because such 
padding materially diminishes 
the stability of the mirror when 
once adjusted to the observer's 
forehead. At both ends of the 
plate there is a long and nar- 
row opening, through which the 
forehead band or strap is to be 
inserted. A word or two with 
regard to the latter. The deal- 
ers are in the habit of furnish- 
ing forehead-bands of elastic 
material covered with black cot- 
ton or silk. In summer time, 
or in a warm room, the dye is 
set free by the perspiration, and 
the physician finds a black stain 
on his temples wherever the 
band has touched the skin. To 
obviate this annoyance the fore- 
head-band should be made partly of undyed leather and partly of elastic ma- 
terial. The leather portions should begin at either end of the forehead-plate 
and should extend to a distance of twelve or thirteen 
centimetres from these. Beyond these limits an elastic 
band of any material or color may be used. The adjust- 
ment of the band to the size of the head is effected by 
means of a buckle. 

As to the mirror itself, I have already described it suf- 
ficiently. Its mode of attachment to the forehead-plate 
is, however, a matter of great importance. All the con- 
trivances used for this purpose are based upon the prin- 
ciple of the ball and socket joint. The majority of them, 
however, as I have already stated, allow so little freedom 
of motion that the physician often finds himself unable 
to use the source of light at his command. In the first 
'place the ball should be attached, through the medium 
of a strong stem (of solid brass), to the metal back of the 
mirror (see Fig. 9). This stem should be fastened to 
the mirror at a distance not exceeding seven millimetres 
from its circumference. The point at which the stem 
broadens out into the ball should also be seven millime- 
tres distant from the back of the mirror, and the ball itself should measure 
about one centimetre in diameter. The socket in which the ball revolves con- 




Fio. 9.— -Forehead-mir- 
ror. Profile view. 



24 DIAGNOSIS AND TREATMENT OP 

sists of two segmental sockets hollowed out of the ends of two brass shanks, 
which are attached, each by a single rivet, to the convex side of the fore- 
head-plate. The length of each shank is five centimetres. By means of 
an adjustable screw, which passes through a slot in one shank, the mobility 
of the joint may be increased or diminished at will. 

If we examine such a mirror as I have endeavored to describe, we shall 
find in the first place that it may be rotated unusually far forward, thus 
enabling the observer to use a source of light situated comparatively high 
above the patient's head. In the second place, the mirror may be rotated 
so far toward one side or the other that the observer can use a source of 
light situated close to the extremes of either side. In the third place, we 
are not so strongly tempted to close one eye, when using the forehead-mir- 
ror, as we are when looking through the central aperture of the hand-mirror. 
Only one eye does the real work of examination in both cases, but in using 
the forehead-mirror we are not conscious, in the slightest degree, that we are 
not observing the object with both eyes in the ordinary manner. Finally, 
if it be found desirable to inspect the illuminated parts in the focal line, — 
or, in other words, to secure the maximum degree of illumination, — the mir- 
ror can readily be rotated in such a manner as to bring the central aperture 
in front of either eye. Unless a mirror can fulfil all these requirements it 
may safely be assumed that the instrument is not as perfect as it is possible 
to make it. 

I have gone thus minutely into the details of construction and advan- 
tages of the forehead-mirror because I have observed that the use of the 
hand-mirror in aural examinations is almost universal, not only in this 
country but also on the continent of Europe. As no one who has ever once 
experienced the comfort of working with a good forehead-mirror would ever 
think of returning to the habitual use of the hand-mirror, I can only ex- 
plain the widespread use of the latter instrument by assuming that no really 
good forehead-mirror has been brought to the notice of the profession. 
The one which I have described is essentially the same as that which was 
first shown to me in 1870 by Dr. Eobert F. Weir of this city, and which 
he had been using, if I remember rightly, for several months previously. 

If for any reason it is thought desirable to magnify the object under 
examination, a lens of suitable focal distance may be held between the eye 
of the observer and the speculum. A person with good eyesight, however, 
will gain but little, if any, additional information by the use of lenses in the 
examination of the ear. 



Introduction of the Speculum and Use of the Reflector. 

If the physician wishes to introduce a speculum into the ear in such a 
manner as to gain a satisfactory view of the deeper parts, and yet not cause 



DISEASES OF THE EAR. 25 

his patient either harm or unnecessary discomfort, he must first gain toler- 
ably clear notions of the anatomy of the external auditory canal, both in 
the adult and in the young infant. For the minute anatomical details I 
must refer the reader either to his manual of anatomy, or to some system- 
atic treatise on the ear. I can here simply allude, in a very brief manner, 
to those peculiarities in the anatomy of the external auditory canal which 
seem to me to have an important practical bearing upon the procedure 
which it is proposed to describe in the present chapter. 

Anatomical considerations. — In infancy, the external auditory canal is al- 
most entirely composed of soft tissues, and the drum-membrane lies but lit- 
tle below the surrounding surface of the skull. In older children and in adult 
life the inner half of the canal consists of a cylinder of bone, the inner end 
of which is spanned by the drum-membrane. There are still other anatomi- 
cal differences between the infantile canal and that of adult life, which bear 
directly upon this question of examinations of the ear. In infants the drum- 
membrane faces chiefly downward, while in adults it faces chiefly outward. 
Again, in infants the soft walls of the meatus tend to collapse and he in con- 
tact with each other, the general direction of the canal from the drum-mem- 
brane being outward and upward. It should also be kept clearly in mind that 
in the infant at birth the little ring of bone (annulus tympanicus) in which 
the drum-membrane is set, and to which the membranous meatus is firmly 
fastened, is itself still very feebly attached to the squamous portion of the 
temporal bone. FinaUy, in adults, the cartilaginous portion of the meatus 
tends to droop downward and forward. As the framework of this portion 
of the canal is not composed of a solid plate of cartilage, but is provided 
with several fissures spanned by elastic tissues, it will be found to possess 
a very considerable degree of mobility. In old age, however, these fibrous 
portions, which play, in a measure, the part of hinges, become stiff and hard 
from the abundant deposit of calcareous material, and the natural mo- 
bility of the canal is thereby seriously diminished. These, I believe, are 
the only important points that have a direct practical bearing upon the 
subject of the introduction of the aural speculum. 

Sources of light. — In the examination of the ear with either the hand or 
the forehead-mirror, it is not necessary to procure any other source of light 
than those which can almost always be found in every house. Direct sun- 
light is so dazzling that we cannot use it with either comfort or advantage. 
Ordinary daylight, such as can be obtained by directing our mirror toward 
the sky above the horizon, or toward the white wall of a house near by, 
generally affords sufficient illumination for ordinary purposes. If the win- 
dow of the room looks out upon a narrow street, it will be found better to 
trust to artificial light. In our larger cities the argand gas-burner prob- 
ably furnishes the most brilliant and steady source of light that can readily 
be found. In office practice some kind of movable fixture should be used, 
in order that the light can readily be placed at different levels, according 



26 DIAGNOSIS AND TREATMENT OF 

to the height of the patient. The ordinary gas-flame, the light of a kero- 
sene lamp, or even that of a candle, will afford all the illumination required 
in the great majority of cases. The interposition of lenses, for the pur- 
pose of increasing the brilliancy of the light, is superfluous. 

Position of the patient in relation to the light. — The physician should try 
and acquire the power to use sources of light situated in all imaginable 
positions. As a matter of course the light must occupy such a position 
that when the observer's face is directed toward the ear that is to be exam- 
ined, he can see the flame or other source of illumination by simply turn- 
ing his eyes in the proper direction. If he is obliged to turn his head, how- 
ever, in order to see the light, it is certain that he will not be able, by 
means of his mirror, to reflect any of it into the patient's ear. In the next 
place, the source of light (if an artificial one) should not be at too great a 
distance from the observer, as in that case the illumination of the auditory 
canal would be rather feeble. The best position for the light is at a point 
a short distance behind and on one or the other side of the patient, not 
more than three feet from him, and about a foot above the level of the ear 
to be examined. If the light occupies a position on the observer's right- 
hand side, and is at the usual height above the patient's ear, there is a 
strong probability that in his manipulations with the right hand he will 
intercept the rays of light, and so shut off his view of the object under ex- 
amination. If it happens, however, to be more convenient for him to use 
a source of light which is situated on his right side, he can readily avoid the 
difficulty just mentioned by raising the light to a higher level, thus enabling 
the rays to reach the mirror over his right arm. Probably the best plan 
for the beginner is to draw his illumination from a source which is situated 
on his left side. After he has acquired practice in using the forehead-mir- 
ror, it will make very little difference to him what position the light occu- 
pies, provided it be not on a lower level than the object under examination, 
and provided, of course, that it can be readily seen by the observer when 
his face is turned toward the ear of the patient. 

The actual examination. — After the physician has acquired a certain de- 
gree of skill in the management of both speculum and mirror, he will find- 
very little difficulty in adapting himself to the different circumstances un- 
der which he may find it necessary to make an examination of the ear. To 
lay down rules for all these varying conditions would simply be a waste of 
time. It will be sufficient if I describe the proper mode of procedure to 
be followed when the patient can be placed in the position which best suits 
the comfort of the physician who makes the examination. Thus, for ex- 
ample, if the left ear be the one that we wish to examine, and if the patient 
be an adult, he should be made to sit in such a position that he will have 
the light in front of him, a little toward his right side, and a few inches 
above the level of his eyes. The physician, of course, sits directly facing 
the patient's left ear. The patient's ear should be as nearly as possible on 



DISEASES OF THE EAR. 27 

the same level with the observer's eyes. Where this is not the case, the pa- 
tient's head must be bent toward one or the other side, until the long axis of 
his external auditory canal corresponds with the observer's axis of vision. 
The next step is to cause the reflected rays of light to fall directly upon 
the ear. In this connection there are one or two practical points to which 
attention should be called. In the first place, it is not necessary, with a 
mirror whose focal distance is about twenty centimetres, to observe whether 
the rays have been brought to a focus in the auditory canal, or several centi- 
metres this side of it in the focal line. In other words, the illumination 
along the focal line, for a distance of several centimetres on either side of 
the focal point, is amply sufficient for all practical purposes. Hence, the 
observer, in examining an ear by the aid of a forehead-mirror, should hold 
his head in that position in which he can best see the parts to be exam- 
ined. In the second place, in our efforts to cause the rays of light to fall 
upon the ear, we should not use the motions of the neck as a means of 
attaining this object. It is far better to fix the head in the proper position 
for observing the parts comfortably, and then rotate the mirror in its ball- 
and-socket joint until we find the position in which it reflects the light in 
the direction desired. This done, the observer is ready to introduce the 
speculum and proceed with the examination. 

Until we have learned by actual experience how large a speculum the 
ear under examination will admit, it is best to begin arbitrarily with one 
of medium size. The ear to be examined, we will suppose, is the left one. 
Holding the instrument between the thumb and forefinger of the left hand, 
and lifting the auricle upward and backward with the right hand, we should 
introduce the speculum cautiously into the orifice of the canal. As we 
push the instrument farther and farther inward, by a sort of boring motion, 
we should keep the eye directed upon the parts illuminated at the bottom 
of the speculum. By thus watching the progress of the inner end of the 
instrument, we shall be able to introduce it as far as we desire without 
causing the patient pain or even discomfort. In lifting the auricle upward 
and backward, while introducing the speculum, it makes no difference 
which hand is employed for the purpose, though it is, of course, easier to 
employ the right hand for the patient's left ear, and the left for his right. 
After the speculum is in position, however, and we desire to use the right 
hand for operative or other purposes, the traction upon the auricle and the 
maintenance of the speculum in a steady position must be given over to 
the left hand. To accomplish this easily, the fore and middle fingers should 
be used for the purposes of traction, while the thumb is left free to steady 
the speculum. 

With regard to the question of how far the speculum should be intro- 
duced into the meatus, it may be said that as soon as the instrument has 
reached a position in which a clear view of the membrana tympani and 
deeper portions of the canal can be obtained, nothing will be gained by 



28 DIAGNOSIS AND TREATMENT OP 

pushing it farther inward. With Toynbee's and Von Troeltsch's specula it 
is an easy matter for a rough or careless operator to injure the deeper parts 
of the canal. With Wilde's conical specula and the broad-mouthed instru- 
ments of Gruber, however, the danger is greatly lessened. 

In infants, the mode of procedure described above must be slightly 
modified, on account of the anatomical differences already mentioned. 
Thus, for example, it is generally necessary to overcome the collapsed state 
of the membranous walls of the canal by pulling the entire canal symmet- 
rically outward. One way of accomplishing this is to exert slight upward 
and backward traction of the upper part of the auricle with one hand, and 
an outward, or outward and downward traction of the lower part with the 
other. A better way is to accomplish this combined movement by means 
of the fore and middle fingers of only one hand, the speculum being held 
in position by the thumb. But the exact mode of arranging the fingers is 
a problem which each one must work out for himself, as the procedure is 
one that scarcely admits of satisfactory description. 



Accessory Instruments used in the Examination of the Ear. 

In a large proportion of the cases that come before us we find that the 
speculum and mirror are the only instruments required for obtaining a full 
and satisfactory view of the external auditory canal and drum-membrane. 
In a certain number of cases, however, we find the view obstructed by the 
presence of various substances such as cerumen, hairs, scales of epidermis, 
pus, etc. These must, of course, be removed, if we desire to see clearly 
the parts beyond, and for this purpose one or more of the following instru- 
ments may be employed : angular forceps, cotton-holders, probes and cu- 
rettes, and the syringe. I mention the syringe last, because I believe it to 
be the clumsiest and in some cases the least efficient of the means enumer- 
ated. Farther on I shall have occasion to discuss the merits of this instru- 
ment more fully. 

A well-constructed pair of angular forceps is an invaluable instrument 
to the aural surgeon. He should be provided with two patterns of the 
instrument — a rather stout pair, which he can use in removing large bodies 
that are near the outer orifice, and a slender pair that can be employed in 
the deeper parts of the canal. 

The long arms or blades of the more slender instrument should measure 
about six and a half or seven centimetres in length. If they are less than 
six centimetres in length, some difficulty may be experienced in illuminating 
the object, which it is proposed to remove, during the actual operation. The 
shorter arms should measure about six centimetres in length, and the spring 
which they form by their union should be quite feeble. A stiff spring is 
very apt to make the operator's hand tremble when he is using the forceps. 



DISEASES OF THE EAK. 29 

At its extreme free end the blade should measure a trifle less than a mil- 
limetre in breadth and hardly three-fourths of a millimetre in thickness. 
From this point it should gradually increase in both dimensions, until near 
the angle it measures 2 J mm. in breadth, and 1^ mm. in thickness. The 
tips of the blades should be provided with short teeth, two on one side, 
and one on the other. "When the blades are closed, and the instrument is 
looked at from one or the other side, no elevation should be visible at the 
angle. The presence of such a hump may seriously diminish either the 
degree of illumination or the extent of the field of vision. In the next 
place, it is important that, vrhen the free extremities of the blades are 
brought close together, the stouter portions at the angle should not be too 
far apart. In a good instrument, if no greater force is exerted than is 
sufficient to make the toothed ends interlock, the distance between the 
blades at the angle should not exceed a millimetre and a quarter or a 
millimetre and a half (or the total diameter of both blades, with the in- 
tervening space, should not exceed five millimetres). Finally, in examin- 
ing a number of these slender forceps, apparently all alike in other re- 
spects, I have observed that, when more force was used than was sufficient 
to bring the blades in contact with each other throughout their entire 
length, the interlocking toothed ends separated, in some instances quite 
widely. "While this is an extremely annoying fault in a pair of forceps, it 
is also one that can be readily discovered at the time of purchasing the in- 
strument. 

Of the stouter forceps, I like best the pattern which is sold in the shojDS 
under the name of Politzer's forceps. As this instrument is not intended 
for delicate work, it is not necessary that I should devote any space to the 
consideration of the details of its construction. As usually found in the 
shops, it is a sufficiently good instrument for all the purposes to which the 
physician is likely to apply it. If he desire to purchase only one pair of 
forceps, it is certainly better for him to have in his possession the slender 
pattern. 

The cotton-holder is an exceedingly useful instrument to the aural sur- 
geon. It consists of a slender rod of malleable steel, about twelve cen- 
timetres in length, which is slightly roughened at one end, for the recep- 
tion of the cotton, and at the other broadens out into a short and rather 
thick handle. For ordinary purposes, a cotton-holder with a shank of 1 mm. 
in diameter is the best size. For the more delicate manipulations which are 
sometimes required in the middle ear (with a perforated drum-membrane), 
an instrument with a shank of not more than half a millimetre in diameter 
will be found more appropriate. It is a common defect in the cotton-holders 
sold in this city that the ends are too much roughened, thus rendering the 
removal of the mass of cotton at times an exceedingly difficult matter. 
"With the nail blade of a pocket-knife, however, it is easy to remedy this 
defect in a very few moments. It is a much more difficult matter to apply 



30 DIAGNOSIS AND TREATMENT OF 

the cotton to the holder quickly, neatly, and firmly. To describe the pro- 
cedure intelligibly is a task which I can hardly hope to accomplish satis- 
factorily, and I therefore prefer to let my readers work out each one a 
method for himself. The most important point, as a matter of course, is 
to cover up the comparatively sharp end of the instrument so thoroughly 
with the cotton that no harm can be done with it. With regard to the 
uses to which the instrument, thus armed, can be put, I may say in general 
that it affords the quickest and best means, known to me, of removing from 
the ear fluid or semi-solid substances. The cotton-holder is also employed 
for other equally important purposes, but of these we shall make mention 
in subsequent chapters. 

Probes and curettes are important accessory instruments. In very many 
cases simple inspection of the parts leads us to wholly erroneous conclusions 
with regard to the true state of things. Thus, for example, simple inspec- 
tion would perhaps justify us in making the diagnosis of a swollen and ulcer- 
ated condition of the posterior half of the membrana tympani ; while inspec- 
tion, combined with the proper use of the probe or curette, might reveal 
the existence of a polypoid mass that originated in the tympanic cavity, 
forced itself through a comparatively small perforation, and then spread itself 
out over the posterior half of the drum-membrane. I might enumerate many 
other pathological conditions which even the most skilful specialist would 
be very likely to interpret incorrectly if he did not use the probe as a means 
of correcting or confirming his first impressions. Of course, if obstacles 
intercept the view, these must first be removed ; and here the probe or the 
curette may also serve an excellent purpose. Both of these instruments, 
however, must be delicately constructed, or the physician will find them of 
very little use, either as aids in making a correct diagnosis, or as substi- 
tutes for the forceps and syringe. The most essential details of construc- 
tion of these instruments are the following : The probe should be made of 
a single rod of soft silver, and for a distance of 8 ctm. from one end it 
should be finished with four sides (each 1.5 mm. in diameter) in order to 
furnish a good hold for the fingers. This handle portion of the probe 
should merge gradually into a slender shank, less than half a millimetre in 
diameter, and terminating in a small knob, about three-fourths of a milli- 
metre in diameter. A total length of 15 ctm. will be found amply sufficient. 
The handles of the curettes should be of the same length as that of the 
probe, but they should be eight- instead of four-sided, and correspondingly 
heavier (diameter of nearly four millimetres). The shank, at the point where 
it broadens out abruptly into the handle, measures 1.5 mm. in diameter ; at 
the point where it joins the ring, it measures but 0.5 mm. in diameter. 
The handles and shanks of the two different sizes of curettes are precisely 
alike ; the only difference is in the size of the rings. Both are oval in shape, 
the smaller one measuring 3 J x 3 mm., the larger one 5 J x 4 J mm. (by ex- 
ternal measurement). Their thickness, from one flat side to the other, is 



DISEASES OF THE EAR. 



31 



about 0.3 mm. ; measured transversely, from the inner to the outer side of 
the ring, it is a trine more than 0.5 mm. in the larger ring, and a trifle less 
than 0.5 mm. in the smaller one. As these instruments are used for a vari- 
ety of purposes, it is sometimes desirable to 
have the shank tempered, in order to give it 
the requisite degree of stiffness, while at other 
times a malleable state of the metal will be 
found preferable. If the larger of the two has 
a tempered shank, the smaller instrument 
may advantageously be allowed to have a 
malleable one, at least for a distance of a few 
millimetres from the ring. 

With regard to the use of the syringe, it is 
not an easy matter to lay down any very well- 
defined rules. To the physician who possesses 
a steady hand and a delicate touch, my advice 
is, to emancipate himself as soon as possible 
from the syringe, and to trust chiefly to his 
probes, curettes, forceps, and cotton-holders, 
for the removal of foreign substances from the 
ear. Skill in the manipulation of these in- 
struments may be cultivated to such a degree, 
that the occasions will be comparatively rare 
when the aid afforded by syringing will be 
required. At such times, however, the sy- 
ringe serves an excellent purpose. Thus, for 
example, when there is soft cerumen in the 
canal, and especially when it is plastered 
over the membrana tympani, or fills the an- 
terior cul-de-sac, its removal can generally 
be effected more rapidly by means of the sy- 
ringe and warm water than by even the most 
skilful employment of the cotton-holder, the 
curette, or any of the other instruments men- 
tioned above. Farther on I will go more 
fully into this subject of the use of the sy- 
ringe as a means of removing cerumen. In 
this place I merely wish to say that my chief 
reason for not employing the syringe more 
often, lies in the fact that I can almost always 
accomplish the desired purpose more rapidly with the different instruments 
mentioned above. Furthermore, syringing has always appeared to me to 
be an exceedingly clumsy way of performing a comparatively simple opera- 
tion. At the same time, I must confess that the requisite degree of manual 



Fig. 10. 
two sizes. 



-Ear-probe and curettes of 



32 DIAGNOSIS AND TREATMENT OF 

skill and delicacy of touch is possessed by so few physicians, that proba- 
bly for a long time to come the syringe will continue to be a very impor- 
tant aid in the diagnosis and treatment of ear diseases. 

A good ear-syringe should have a piston that works easily. This is the 
first and most important requirement. In the next place, it should be pro- 
vided with some contrivance which will enable the operator to alternately 
fill and discharge the instrument with one hand. This object is commonly 
attained by having the handle of the piston terminate in a ring large enough 
to admit the thumb, while two other rings large enough to admit the fore 
and middle fingers are fastened opposite to each other on the base of the 
cylinder. In the hard-rubber ear-syringes the neck of the cylinder is hol- 
lowed out in such a manner as to afford to the fore and middle fingers all 
the support that they receive from the rings in the metal instruments. With 
regard to the size of cylinder best adapted to the requirements of a good 
ear-syringe, I may say that, in general, it is better to employ an instrument 
of rather large capacity. The smaller syringes require to be filled so fre- 
quently that the patient's ear is apt to be subjected to a great deal of unne- 
cessary handling. If carefully manipulated, the slender conical nozzle is 
probably the best that can be used. At its point it should not measure 
more than three and one-half or four millimetres in diameter. 

The water employed in syringing the ear should have a temperature of 
from 95° to 100° F. If it be too cold, we may produce in the patient a sen- 
sation of faintness, nausea, or dizziness. The same effects may also be pro- 
duced by injecting the water with too great force. 

Finally, a word with regard to the different steps of the procedure. 
The patient's neck and shoulder should first be protected with a towel, and 
he should be given a bowl or mug to hold beneath his ear. The shallow 
hard-rubber or metal basins sold by the instrument-makers for this latter 
purpose are thoroughly unpractical. A sudden motion of the patient's 
body is apt to cause the contents of the basin to spill over upon his per- 
son, while if a mug, bowl, or other deep vessel be used, the same accident 
is much less likely to occur. In the majority of cases the bowl or mug* 
may be used both as a reservoir from which to fill the syringe and as a re- 
ceptacle for catching the water that runs out from the ear. If the proper 
conveniences, however, are at hand, it is better to fill the syringe from a 
separate vessel, as sometimes the matters which are washed out from the 
ear block the canal of the nozzle, and so cause trouble. After we have 
filled the syringe with the right hand, we must straighten the patient's 
external auditory canal with the fingers of the left hand, in the manner 
described on page 27. After this has been done, the nozzle is to be 
introduced a short distance, — roughly estimated, not more than half an 
inch, — into the meatus, and the water thrown in with little or great force, 
according to the nature of the conditions which led to the use of the 
instrument. If we are not pointing the syringe in the right direction, 



DISEASES OF THE EAE. 33 

or if we have pushed the nozzle too far into the ear, the patient will be 
very likely to reveal the fact by the expression of his countenance. No 
description, however, can serve as an adequate guide to the successful 
performance of this operation, which physicians are very apt to consider as 
a very simple task, but which in reality is often a very difficult one. In 
infants the hard rubber or metal syringe must be used with great caution. 
The douche or the bulb-syringe is a much safer instrument for this class 
of cases. The nozzles usually supplied with the douche are either so large 
that it is impossible to do effective work with them, or so slender and 
sharp that they may easily injure the canal or even the drum-membrane 
itself. In some of the shops it is now possible to purchase a form of nozzle 
which is free from both of these objections (Fig. 11). It is made of hard 
rubber, and is provided with four prongs which are symmetri- 
cally placed around the nozzle, each at a distance of eight mil- 
limetres from the free end. The diameter of the nozzle at the 
tip is three and one-half millimetres ; at the bases of the 
prongs it is about four raillimetres. The prongs themselves 
project about six millimetres from the sides of the nozzle, and 
they are inclined a little backward away from the tip. In adults 
it may be found advantageous to use a nozzle with a somewhat 
longer tip — one, for instance, that measures ten or eleven mil- 
limetres in length, instead of eight millimetres. Both sizes 
can be purchased, but the smaller size will almost always do 
equally good service in both adults and children. "With such 
a nozzle the patient himself, or the mother, in the case of a 
child, can easily be taught to cleanse the deeper parts of the Fj 
external auditory canal as safely and as efficiently as it can hard-rubber ear- 
be done by the physician with a well-constructed syringe. nozzle - (larger 
In the case of the douche the desired degree of force can 
be given to the stream of water by lowering or raising the reservoir. 
Due allowance must be made for the cooling off of the water in its passage 
through the long rubber tube, and, just before introducing the nozzle into 
the ear, we must be careful to let the water escape from the nozzle for a 
moment or two, until its temperature, as it flows from the instrument, 
reaches the proper height. The cheapest and perhaps the best form of 
receptacle is that which is sold under the name of Clark's douche. It is 
made of tin and will hold at least a quart of fluid. Care must be taken not 
to pour too small a quantity of warm water into the receptacle, for it is 
only by drawing our supply from a comparatively large bulk of fluid (at 
least a quart) that we can prevent an inconveniently rapid lowering of its 
temperature. 

However valuable the douche may be, it must be conceded that it is a 
rather awkward apparatus to use in cases where the canal requires to be 
cleansed frequently. The bulb-syringe, armed with the hard-rubber 
3 



34 



DIAGNOSIS AND TKEATMENT. 




Fig. 12.— Simple pattern of ear- 
douche. 



pronged ear-nozzle described above, will be found a much easier instrument 
to manage, and one that is equally effective. The Davidson syringe, which 
may be found in almost every household, can be 
used as an ear- syringe in an emergency. A better 
pattern, however, especially for use in young chil- 
dren, is that represented in the accompanying cut 
(Fig. 12). The rubber bulb has an opening at one 
end for the reception of a tightly fitting hollow 
stem, five or six centimetres in length. One end of 
a piece of soft-rubber tubing, from ten to fifteen 
centimetres long, is pushed down over the free end 
of this stem, and the other is armed with the prong- 
ed nozzle already described. This form of bulb- 
syringe is so simple in its construction that it is 
hardly possible for it to get out of order, and if 
the piece of rubber tubing that connects the noz- 
zle with the bulb is not too long, we may use the 
instrument quite readily with one hand. Before 
the water is injected into the ear, care should be taken to fill and empty 
the instrument two or three times in succession, for the purpose of warm- 
ing it thoroughly. 

Tn the foregoing description of instruments, I have mentioned only 
those which the physician may find it necessary or desirable to use in ob- 
taining a satisfactory view of the membrana tympani and deeper parts of 
the external auditory canal. Those instruments which are used more par- 
ticularly as means of ascertaining the condition of the Eustachian tube and 
middle ear, or for strictly therapeutic purposes, will be described farther 
on, in connection with the dif- 
ferent forms of disease. 

Note. — I find, on reading over 
the preceding chapter, that I have 
omitted to mention the very impor- 
tant fact that the forehead-mirror 
is to be worn in the manner repre- 
sented in the accompanying cut, i.e., 
with the ball-and-socket joint rest- 
ing upon the bridge of the nose, and 
the mirror itself projecting at a still 
lower level. As our ordinary sources 
of light are almost invariably situ- 
ated at a higher level than that of 
our eyes, the plan, often adopted, of 
resting the mirror against the fore- 
head, will be found rather awkward in aural examinations. On the other hand, the 
plan represented in the cut is that which I have habitually used in practice since 1870, 
and I can therefore vouch for its usefulness. 




Forehead-mirror in actual use. 



CHAPTEE HI. 
DISEASES OF THE AUKICLE. 

This part of the organ of hearing is subject not only to all the diseases 
which affect the skin in other parts of the body, but also to those which 
attack cartilaginous structures. It shares with the nose, the fingers, and 
the toes, a strong predisposition to become frost-bitten, and stands second 
only to the nose in its liability to receive injuries of various kinds. Owing 
to the practice of piercing the lobes for the introduction of ear-rings, the 
development of fibroid tumors is far more common in this locality than in 
any other part of the body. It is only in these respects, however, that the 
auricle differs from other parts of the surface of the body in its tendency to 
become diseased. 

The commonest affection ' to which the auricle is liable, is 

Eczema. 

Among the children of the poorer classes eczema of the auricle is an 
extremely frequent disease. If less frequent among the well-to-do classes, 
it is certainly by no means a rare affection even among them. Again, in 
old age and in the middle period of life, it is a quite common disease. In 
a certain proportion of the cases, it develops on other portions of the skin 
at the same time, e.g., on the hairy scalp or in the mastoid region. In 
children it is often associated with a conjunctivitis, and the coexistence of 
the two diseases suggests the probability that the irritating secretions of 
the auricle have been transferred by the child's fingers to the eyes. In its 
mildest and simplest form, eczema of the auricle manifests itself as a red- 
dening and infiltration of the skin at one or more points. The favorite 
places are those spots where the skin is folded upon itself, as the fossa 
helicis, and the angle behind the ear, where the skin is reflected from the 
auricle upon the mastoid process. The disease is observed at least equally 
often at the orifice of the external auditory canal, and extending from there 
forward over the tragus, and downward over the lobule, — in other words, at 

1 The Report of the N. Y. Eye and Ear Infirmary for 1878, shows that out of 
eighty-five cases of disease of the auricle, there were fifty-four of eczema. 



36 DIAGNOSIS AND TREATMENT OF 

points where there is apt to be a good deal of friction, or where an irritat- 
ing discharge from the meatus may act as an exciting cause. At a later 
stage these reddened and infiltrated spots secrete a fluid which soon be- 
comes inspissated, forming crusts or scabs. In many cases actual ulcera- 
tion takes place beneath the scabs ; and this is particularly apt to occur in 
the incisura intertragica, in the fossa helicis, and in the angle behind the 
ear. In exceptional cases the entire auricle and immediate surroundings 
present an almost continuous mass of scabs. Again, it is not a rare occur- 
rence for a diffuse and quite painful inflammation of the entire auricle to 
develop during the course of what appears to be a very trifling attack of 
eczema. The whole organ swells up to fully twice its natural size, and pre- 
sents a vivid red color ; the orifice of the external auditory canal becomes 
obliterated, — in a word, the picture presented is that of an acute attack of 
erysipelas. 

We may also, in certain cases, see the eczema manifest itself in the 
form of an equally vivid reddening and equally marked infiltration of the 
entire auricle, but without pain and with but very little tenderness. 

Finally, in another group of cases, a desquamative process, confined to 
certain portions of the auricle, seems to constitute the most characteristic, 
if not the only, manifestation of the disease. The intervening portions of 
the skin appear to be perfectly healthy, and even those parts which are 
desquamating or are covered with scab-like formations, present a pale and 
uninflamecl appearance. The term chronic eczema is usually applied to 
this class of cases, but it may be applied with equal justice to other forms 
of the disease. 

Etiology. — I have no intention of introducing here a disquisition on the 
etiology of eczema in general. I simply wish to call attention to the very 
intimate relation that exists between the development of an eczema of the 
auricle, and the character of the diet habitually used. This relation is so 
strongly marked in young children, that when a case of eczema auris is 
brought before us, we can safely accuse the parents of habitually feeding 
the child with tea, coffee, cakes, pies, salt meat, peanuts, or any other arti- 
cle of food which even an adult stomach often finds difficulty in digesting. 
In the middle and lower classes, children begin to feed upon this sort of 
diet at a remarkably early age. In adults I have occasionally been able to 
trace a similar connection between the development of eczema of the ear, 
and the condition of stomach digestion. I remember one case in particu- 
lar. The patient, a man of about thirty-two, led a sedentary life. His ear, 
in spite of all treatment, presented a decidedly unpleasant appearance, and 
the tendency of the disease was to grow worse rather than better. His 
business compelled him to leave the city and spend several months in the 
far west, where he led a very active life, and subsisted on a very simple 
diet. When he returned to the city scarcely a trace of the eczema could 
be seen. 



DISEASES OE THE EAK. 37 

In a few instances I have observed the coexistence of a marked naso- 
pharyngeal catarrh and eczema of the auricle, and have suspected that the 
former affection was in some way connected with the causation of the 
eczema. We might then, in both classes of cases, speak of the eczema as a 
reflex affection dependent, on the one hand, upon irritation of the stom- 
ach, on the other, upon irritation of the naso-pharynx. 

Diagnosis. — Where the disease localizes itself in distinct reddish and 
in filtrated spots, which are separated from each other by healthy skin, I 
know of no other affection with which it might possibly be confounded. I 
have seen one case of deep ulcerations of the auricle, which presented at 
first view every appearance of that variety or stage of eczema which is char- 
acterized by the formation of scabs or crusts without noticeable redness of 
the surroundings. In this case, however, the removal of the scabs dis- 
played a group of deep ulcers, with excavated edges, and with bases resting 
directly upon the cartilage. The resemblance between the conditions was 
therefore merely an external one. A diffuse general inflammation of the 
auricle may readily be taken for a diffuse eczema of the organ. I am not 
sure that a positive distinction can be made between these two conditions 
in all cases, — certainly not by inspection alone. The previous history of the 
case may aid greatly in clearing up the nature of the affection. Erysipelas 
can be diagnosed with positiveness if the redness is found to spread rather 
rapidly to the adjacent cheek or forehead, and if it is accompanied by an 
elevation of the body temperature. 

Prognosis. — In children a favorable prognosis may be given with very 
little hesitation. In adults, and especially in old people, a guarded prog- 
nosis must be given, as the tendency to relapses is very common. 

Treatment. — Careful inquiry should be made, first into the character of 
the patient's diet, and then into that of his habits with regard to bathing 
and outdoor exercise. In children a complete and permanent cure may 
often be attained by simply restricting the diet to such simple articles as 
milk, oatmeal, hominy, fresh meat and vegetables, and light bread. Pas- 
try, pies, cakes, salt meat and pork, tea and coffee must be rigidly ex- 
cluded. In adults, it will generally be found easier to induce the patient 
to take an adequate amount of exercise in the open air, than to persuade 
him into excluding certain articles of food from, his daily fare. If possible, 
he should be induced to do both. 

In private practice I have rarely seen the aggravated forms of chronic 
eczema of the auricle, and have therefore had very little occasion to use ar- 
senic as an internal remedy. In the few cases in which I prescribed it (5 
drops of Fowler's solution of the arsenite of potassa, to be taken three 
times a day after meals, in a little water), I did not observe such a marked 
improvement in the condition of the auricle as would justify me in speak- 
ing favorably of its curative effects upon eczema of this part of the body. 
In dispensary practice the aggravated forms of eczema are comparatively 



38 DIAGNOSIS AND TREATMENT OF 

common, but in these cases I have thus far trusted almost wholly to local 
applications and dietetic rules ; not caring to prescribe such a powerful 
remedy to patients who, as a rule, visit the institution at extremely irregu- 
lar intervals. 

Local applications form a very important part of the treatment of eczema 
of the auricle. In the acute stage, if there happen to be pain and tender- 
ness, it may be desirable (though only in adults) to apply leeches, for the 
purpose of allaying the pain and diminishing the inflammation. It is rare, 
however, that local bloodletting seems indicated in these acute cases. If 
leeches are used, they should be applied in the immediate vicinity of the 
tragus or in the angle behind the ear. Cloths dipped in some cooling and 
astringent lotion, such as the lead and opium wash, or in simple water to 
which alcohol or eau de cologne may be added in varying proportions, will 
generally be found sufficient to allay all the acute symptoms. Afterward, 
if no crusts have formed in the meantime, we may apply some oleaginous 
preparation directly to the affected skin. If crusts have already formed, 
these must first be removed with a sponge dipped in hot water ; and if the 
skin is actually ulcerated, I am in the habit of cauterizing such ulcers lightly 
with nitrate of silver in the form of a bead or solid stick. The chief value 
of the different oleaginous preparations lies, I imagine, in their power to 
exclude the air from the parts affected, rather than in the medicinal virtues 
of the drugs which enter into the composition. There can be very little 
doubt, however, that some of these drugs do exert a decided curative in- 
fluence. This, I believe, is true more particularly of the oil of Cade and of 
certain preparations of lead. I formerly used the oil of Cade in the form 
of an alcoholic solution (one or two drachms of the oil to seven or six 
drachms of alcohol), and obtained fair results from its use. Of late I have 
substituted vaseline for the alcohol, and am well satisfied with the results 
which I now obtain with this combination. The patient is advised to apply 
it twice a day, at night just before retiring, and again the next morning. 
At night it may be applied very freely, as some kind of cap can be worn for 
the purpose of protecting the pillow. In the morning, if the patient is 
obliged to leave the house, the preparation should be applied so lightly that 
the ordinary observer will not be able to discover its presence. Each time, 
before the ointment is applied afresh, the auricle should be washed with tar- 
soap, or castile-soap, and warm water ; and in drying the parts the patient 
should simply make pressure with the towel, and not rub the ear in the 
ordinary manner. 

Of the lead preparations, I have used only one, viz., Hebra's diachylon 
ointment. The formula for this ointment, as prepared in Vienna, is (ac- 
cording to Gruber) 1 the following : 



Ueber Eczem am ausseren Ohrtheile. Monatsch. f. Ohrenheilk. Nov., 1867. 



DISEASES OF THE EAE. 39 

^ . Olei olivarum optimi § xv. 

Lythargiri f iij. et 3 vj. 

Coq. 1. a. in unguentuin molle, dein adcle 3 ij. 
olei lavand. 
M. Ft. unguentum. 

Unfortunately, it is not easy to procure this ointment even in a large 
city like New York, and for this reason I have not prescribed it as freely as 
I have the oil of Cade preparation. In one or two instances I have known 
it to prove successful when all the other well-known remedies had failed. 

The benzoatecl oxide of zinc ointment is a favorite remedy with many 
physicians. I have used it a great deal in children, and have been in the 
main well satisfied with the results. Vaseline alone, in mild cases, seems 
to accomplish nearly as good results as are obtained by the employment of 
the other remedies mentioned. 

Finally, in a certain proportion of the thoroughly chronic cases, in which 
all the ordinary preparations seem to have been powerless to affect even an 
amelioration of the unsightly condition of the ear, decided good may be 
accomplished by painting the diseased parts thoroughly (after all oily sub- 
stances have been removed), from time to time, with acetuin cantharidis. 

It is a common mistake to stop using these local applications as soon as 
the ear appeal's to have regained its natural condition. It will be found 
safer to continue the treatment faithfully for at least a week or ten days 
after a cure has apparently been effected. 



Inflammation of the Auricle. 
(Furuncles. Diffuse inflammation.) 

In my experience, furuncles, of sufficient size to lead the patient to con- 
sult a physician, develop very rarely on the auricle. In fact, I can find but 
one such entry in my records. As furuncles of the external auditory canal 
possess the same significance as these do, and as the treatment is essen- 
tially the same in both cases, the reader is referred to the chapter on Dis- 
eases of the External Auditory Canal, where this condition is discussed at 
greater length. 

Diffuse inflammation of the entire auricle is observed in its purest type 
in cases in which hot poultices have been used to excess. After the auri- 
cle has been exposed for a certain length of time to the combined effects of 
the heat and the moisture, it becomes highly congested and slightly tender 
to the touch. The appearance of the organ is precisely the same as if it 
were affected with acute erysipelas. If the exposure is kept up for a still 
greater length of time, the auricle becomes quite painful and very much 
swollen. Abscesses, I am told, may even form at different points. As al- 



40 DIAGNOSIS AND TREATMENT OF 

ready stated in the preceding section, such a general inflammation of the 
auricle may develop in the course of an eczema, and I have occasionally 
seen it in connection with a circumscribed inflammation of the outer por- 
tion of the external auditory canal. In these cases, however, it was not 
quite clear whether the diffuse inflammation of the auricle was to be inter- 
preted as an actual extension of the more localized process in the meatus, 
or as the result of the application of hot poultices. 

At first sight one might hesitate to decide whether the disease under ob- 
servation was a bona fide attack of erysipelas, a commencing perichondritis, 
or a simple diffuse inflammation of the auricle, limited chiefly to the struc- 
tures of the skin. The limitation of the redness to the auricle and the prob- 
able absence of any noticeable elevation of temperature would favor the ex- 
clusion of erysipelas. The subsequent course of the case would soon en- 
able one to exclude perichondritis, which runs a slow course and generally 
begins in a more circumscribed manner. 

As the disease disappears quite rapidly as soon as the exciting cause 
has been removed, it is not necessary to make any additional remarks on 
the subjects of prognosis and treatment. 



HEMATOMA AUEIS. PERICHONDRITIS. 
(Othematoma. Chondromalacia. Chondromalacosis. ) 

These conditions are so closely allied to each other that it is better, I 
believe, to consider them together in one section. The term hematoma 
auris, or othematoma, is usually applied to a peculiar swelling of the auri- 
cle, which is most frequently observed in the insane, and which is chiefly 
due to the escape of a varying quantity of blood either between the carti- 
lage and the perichondrium, or into the substance of the cartilage. The 
term perichondritis is restricted to those cases in which the symptoms of 
redness, pain (usually slight), and slowly increasing swelling, point very de- 
cidedly to processes that are chiefly inflammatory in their nature. With 
othematoma of the insane I have had no practical experience whatever, 
and must base my remarks wholly upon information gained through read- 
ing ; with perichondritis I have also had very little experience, as the dis- 
ease is comparatively rare. I am persuaded, however, that no sharp divid- 
ing line can be drawn between the two classes of cases, whether considered 
from an etiological, a pathological, or a therapeutical standpoint. 

Etiology and Pathology. — Exposure to severe cold or extreme heat pro- 
duces an inflammation to which the term perichondritis may fairly be ap- 
plied. Violence may also produce the same pathological manifestations. 
Finally, in a few cases, no exciting cause can be discovered ; the disease is 
then said to be idiopathic. In these cases the patients are generally found 
to be in a poor state of nutrition, and, in the absence of any other adequate 



DISEASES OE THE EAR. 



41 



cause, we are almost compelled to assume that some local nutritive disturb- 
ances — probably of the same nature as those which are now generally ad- 
mitted to be the chief factors in the production of the typical othematoma 
— have given rise to the perichondritis. 

The pathology of othematoma proper has for many years past been a 
fruitful subject for discussion. Some advocate the doctrine that this lesion 
is peculiar to the insane, and depends upon a pathological condition of the 
brain. This is the view taken by Dr. Hun, 1 of Albany, who has written a 
very interesting paper on the subject of heematoma auris. Others maintain 
that the lesion is always produced by violence, and that it occurs more fre- 
quently among the insane, simply because they are peculiarly liable to vio- 
lence. Finally, a third party maintains that the othematoma is not one of 
the pathological lesions of insanity, but that the surroundings of the insane, 
and the debilitated condition which so generally accompanies insanity, are 
the real reasons for its so frequent occurrence among that class of indivi- 
duals. This is the view taken by Virchow in his treatise on tumors, and 
the exhaustive researches of Luclwig Meyer, 2 Pareidt, 3 Gudden, 4 Pollak, 5 and 
Haupt, 6 confirm it in the strongest possible manner. The essential facts 
developed by these investigations are the following : 

First, degenerative changes are quite uniformly found in the cartilagi- 
nous framework of the auricle in cases of othematoma of the insane. These 
changes are of such a nature that Pareidt very properly termed the disease 
a chondromalacia,' 1 or softening of the cartilage. The progress of the affec- 
tion is described by Ludwig Meyer essentially as follows : Hematoma 
auris begins as a degeneration and softening of the cartilage at one or more 
spots. A gelatinous material takes the place of the hard cartilage. As the 
degenerative process goes on, newly formed blood-vessels shoot out from 
the perichondrium, or from the vessels that pierce the cartilage at different 
points, into these softened spots. The newly formed capillary vessels are 
quite large, and their walls are very thin and richly supplied with nuclei. 



1 American Journal of Insanity, July, 1870. 

2 Virchow's Archiv f. path. Anat., etc. Bd. XXXIII., Heft 4, 1865. 

3 De Chondromalacia, etc. Dissertatio inauguralis. Halle, 1834. 

4 Ueber den mikroskopischen Befund in traumatisch gesprengten Ohrknorpel. 
chow's Archiv f. path. Anat. Bd. LI., 4, p. 157.; LIX, 2, p. 303. 

6 Monatschrift fur Ohrenheilkunde. Berlin, July, 1879. (Reviewed in Vol. I. 
4, of the American Journal of Otology.) 

6 Gustav Haupt : Ueber das Othgematom. Dissert, inaugur. Wurzburg, 1867. 
viewed in A. f. 0. Vol. IV., p. 143. (Marked changes found in the cartilage of the ap- 
parently healthy ear of an insane person whose other ear had been the seat of a well- 
marked othsematoma. ) 

1 Loosely used in the sense of chondromalacosis, which means a softening of the 
cartilage. According to Kraus (Kritisch-etymologisches medicinisches Lexikon. Got- 
tingen, 1844), the term chondromalacia means simply a softness of the cartilage. 



Vir- 



No. 



Re- 



42 DIAGNOSIS AND TKEATMENT OF 

Thus, we have two different processes going on side by side at the same 
time — a softening of the cartilage, and a granulation process on the part of 
the perichondrium. 

In the second place, a careful macroscopical and microscopical examina- 
tion of a large number of ears, taken from patients who had died from all 
sorts of diseases in the hospitals, but who had never manifested any symp- 
toms of insanity, reveals the fact that precisely the same changes as those 
just described take place in the auricles of the mentally sane. According 
to the statement of Pollak, whose researches are probably the most recent, 
small nodules, varying in size from a mustard-seed to a lentil, are occasion- 
ally found in the cartilaginous portion of the external meatus, and especially 
in the anthelix. In these, when cut open, it is easy to detect, even with 
the naked eye, a departure from the normal condition of the reticular car- 
tilage ; in some cases, in fact, it will be found that a distinct cavity has 
already formed. Microscopic examination also reveals spots where the car- 
tilage has broken down into a mass of granules, and others where evidences 
of new growth of tissue are distinctly recognizable. 

In the third place, the number of instances of the occurrence of fully 
developed othematoma in persons who are perfectly free from any mental 
disorder whatever, is constantly increasing. 

These facts justify the belief that insane persons are more liable to the 
disease under consideration, simply because malnutrition reaches a higher 
grade among them (taken as a class) than among the mentally sound. The 
new growth of unusually large and thin-walled capillary blood-vessels also 
furnishes an explanation of one of the most striking phenomena of othema- 
toma, viz., the escape of a comparatively large amount of blood, either be- 
tween the perichondrium and the cartilage, or into the substance of the 
cartilage. It can readily be understood how a very trifling exciting cause, 
such as a slight blow, the pressure of a hard pillow, or even the reflex con- 
gestion following some mental emotion, may lead to the rupture of one or 
more of these delicate vessels and produce the characteristic accumulation 
of blood. 

Course of the disease in the mentally sane. — It rarely happens that the 
physician has an opportunity of seeing a case of idiopathic perichondritis, 
in its incipient stage. The patient generally waits until the discomfort or 
pain is sufficiently great to make him feel the need of medical aid, and usu- 
ally by that time the disease has reached its highest stage of development. 
The following case is a good example of an idiopathic perichondritis of a 
comparatively mild type : 

Female, thirty years of age, saleswoman in a retail shop, and in decid- 
edly poor general condition. She presented herself at the N.* Y. Eye and 
Ear Infirmary, on the 1st of November, 1878, and gave the following his- 
tory : About ten days ago she first noticed some irritation at the upper 
part of the right auricle, not far from the helix. She had not received any 



DISEASES OF THE EAR. 43 

injury at this point, nor could she think of any other cause for the develop- 
ment of the soreness in that particular place. In the course of a few clays, 
a circumscribed swelling developed at this spot, and she then consulted her 
family physician. He made two small incisions into the swelling, one at the 
upper, the other at the lower limit of the tumor, evacuated the fluid con- 
tents, and then passed a seton into one opening and out through the other. 
After this the auricle swelled up rapidly and became very painful. At the 
time of her visit to the Infirmary, the tumor was fully as large as a butter- 
nut. It presented a smooth, red, and inflamed appearance, and occupied 
the anterior aspect of the upper two-thirds of the auricle. There was also 
some oedema of the skin above and behind the ear. The seton was still in 
place, and on removing it a thin fluid spurted out from one of the openings. 
By aid of the probe it was ascertained that a large cavity existed, the pos- 
terior wall of which seemed to be formed by the denuded anterior surface 
of the cartilage. The two openings were converted into one by an incision, 
the cavity was carefully cleansed, and a tent was introduced to prevent the 
edges of the wound from uniting. When the contents of the cavity were 
evacuated, it was observed that the larger part consisted of thick, almost 
gelatinous pus, while the smaller part was apparently a thin serum. The 
patient was ordered to take twenty drops of the niuriated tincture of iron 
three times a day, and to lay cloths wet with the lead and opium wash upon 
the inflamed auricle. 

On the second day of November she visited my office, and reported that 
the pain had very markedly abated. I removed the tent and, in so doing, 
afforded escape to a moderate amount of thick pus and some thin, serous 
fluid. The parts surrounding the cavity were found to be still very much 
swollen. From the uniform smoothness of the posterior wall of the 
cavity it was inferred that no destruction of cartilage had taken place, and 
that the disease was, strictly speaking, a perichondritis, with effusion be- 
tween the cartilage and the perichondrium. From this time forward the 
patient was visited regularly by my colleague, Dr. George B. Hickok. The 
cavity was daily cleansed, and then mopped out with tincture of iodine ; 
afterward, moderate pressure was applied, for the purpose of keeping the 
walls of the cavity in close apposition. J In less than three weeks the cavity 
had completely healed, and the auricle had so nearly returned to its natural 
condition that there could no longer be any reasonable doubt about the 
speedy disappearance of all traces of the disease. 

Chimani 2 reports an equally typical case of idiopathic perichondritis, 



1 Two short and flat bits of wood were employed for this purpose ; one being placed 
behind, the other in front of the swelling, and rubber bands being used to exert the 
requisite pressure. The localization of the pressure was secured by interposing suita- 
ble pads of sheet lint between the skin and the bits of wood. 

2 Archiv fur Ohrenheilkunde, Bd. II., S. 169. 



44 DIAGNOSIS AND TREATMENT OP 

which occurred in a young man, twenty-three years of age. The swelling 
was incised, and complete recovery took place in a little more than four 
weeks, without any deformity. Wendt J reports a similar instance of the 
development of a "spontaneous hematoma" in a strong and perfectly 
healthy young man, twenty years of age. Brunner 2 also reports a similar 
occurrence in a perfectly healthy individual, thirty-two years of age. In 
this case, however, it is quite probable that the cartilage was primarily dis- 
eased, as a certain degree of deformity remained after the parts had healed. 
Furthermore, the patient had already a few years previously experienced a 
similar inflammation of the other auricle, and an examination revealed the 
fact that some deformity still remained at the seat of this former attack. 

In a second case which came under my observation, almost precisely the 
same conditions were presented as in the case which I first described. The 
same plan of treatment was followed, and very nearly all traces of the dis- 
ease disappeared. The two cases, however, differed from each other in the 
following particulars : a frost-bite was clearly the exciting cause in the lat- 
ter instance ; and, furthermore, the contents of the sac were sufficiently 
bloody to communicate a bluish tint to the outside of the tumor. As no 
notes were kept of this case, I cannot say positively whether the fluid con- 
tents of the sac were simply stained with the coloring matter of the blood, 
or whether solid clots were also found to be present. 

Dr. Charles J. Kipp, of Newark, N. J., has reported 3 a somewhat simi- 
lar case of perichondritis — or spurious othematoma, as he terms it — of 
both auricles, the result of a burn. " The auricles were pushed out from 
the head, and the upper two-thirds of both were pear-shaped. The swell- 
ing was greatest at the top, and measured about an inch and a quarter 
from before backward. The auricles were hot and very sensitive to the 
touch. The surfaces of the swellings were convex and smooth, and the 
skin of normal color, but it looked as if it had been blistered. Fluctuation 
could be distinctly felt in both. An incision through the entire length of 
each swelling gave escape to a considerable quantity of a yellowish, glairy 
fluid. The swellings did not collapse after the evacuation of their con- 
tents. In both was found a cavity of about the size of a hickory-nut, lined 
by a smooth, shining membrane. The anterior wall of both was about a 
line thick, and was apparently composed of thickened perichondrium ; the 
posterior wall was formed by the cartilage. Under the daily application of 
tincture of iodine to the interior and exterior of the swellings, the auricles 
gradually diminished in thickness, and at the end of two months they had 
regained their normal size and shape. The only deformity remaining when 
I last saw him was a wrinkled condition of the fossa helicis." 



ibidem, Bd. III., S. 29. 

2 Ibidem, Bd. V., S. 26. 

3 Transactions of the American Otological Society for the year 1873. 



DISEASES OF THE EAK. 45 

Finally, in a third case which came under my observation, the condi- 
tions found were essentially different from those observed in the two pre- 
ceding cases. The patient, a man thirty years of age and in robust health, 
consulted me on the 11th of December, 1878. He stated that four years 
previously both of his ears had been frost-bitten, and that from that time 
to the present he had had four sores on the left ear and two on the right, 
as the results of the acute inflammation which immediately followed the 
freezing of the parts. All efforts to make these ulcers heal permanently 
had failed, although dining the summer season some of them often pre- 
sented all the appearances of having spontaneously healed. As soon as cold 
weather returned, however, these spots again became scabbed over. Upon 
examination, I found four spots on the left auricle and two on the right, 
occupied by scabs of moderate thickness. They were nearly circular in 
shape, and measured from five to eight millimetres in diameter. Five out 
of the six scabs were located on the outer aspect of the helix, above the level 
of the orifice of the external auditory canal ; the sixth was located on the 
anthelix, on the same level with the external orifice. The edges of the scabs 
seemed to rest upon healthy skin. After they had been removed, it was 
ascertained that they each covered an ulcer with sharply defined and un- 
dermined edges. The bottom of each ulcer was smooth, hard, and of a 
pale color. The undermined edges had a markedly bluish hue, which 
faded gradually into that of the perfectly sound skin. 

Nitrate of silver, tincture of iodine, and pure nitric acid were tried in 
succession, at brief intervals, but none of these reagents seemed to induce 
the slightest evidence of a healthy reparative process. I then tried the fol- 
lowing plan : with a pair of curved and slender-pointed scissors I cut away 
the bluish undermined edges ; then, as soon as the bleeding had ceased, I 
applied compound tincture of iodine freely to the base of the ulcer, and to 
the suiTOunding raw surface. A very thin layer of cotton -wool was next 
laid upon the exposed surface, and then liquid collodion was applied for 
the purpose of supplying an artificial scab. At the end of three or four 
days the collodion and cotton were removed, and the ulcer was found to be 
healing slowly both from the edges and from the bottom. The compound 
tincture was applied a second time and the wound was sealed up again 
with cotton and collodion. Nine such applications in all were made during 
the latter part of December, and, on the second day of January, I found the 
newly formed skin firm and dry over the spot which before had been the 
seat of the ulcer. The depression of the surface at this point was too 
slight to attract attention. 

The remaining ulcers were treated in much the same manner as the first 
one, and with equally good results. 

In the cases described above it is reasonably safe to assume that the 
cartilage itself was either not at all involved, or at most, only very superfi- 
cially. The term perichondritis seems therefore more appropriate for this 



4(5 DIAGNOSIS AND TKEATMENT OF 

class of cases than either of the other expressions — othematoma and hema- 
toma amis. It would be better if we could abandon the use of these two 
terms altogether, and employ some term which indicated the essential na- 
ture of the disease, and not merely one of its comparatively unimportant 
manifestations — the escape of blood into the tissues. Pareidt's chondroma- 
lacia (or the correct expression, chondromalacosis) is certainly the best term 
that has thus far been proposed. I hesitate, though, to urge the abandon- 
ment of terms to which we have all been habituated for so long a time. 

I have already said that this chondromalacosis is occasionally observed 
among the mentally sane. Through the courtesy of Dr. Oren D. Pomeroy, 
of this city, I once had the opportunity of seeing a very marked instance of 
this disease. 1 The patient, a cooper, forty-two years of age, and of perfectly 
sound mind, gave the following history : In the early part of May, 1874, he 
experienced a violent pain in the right ear, which continued for eleven days, 
with very little abatement. A discharge of thick creamy pus then made its 
appearance in the external auditory canal. Five days after the discharge 
began, he presented himself at the Brooklyn Eye and Ear Hospital. Ow- 
ing to the swollen condition of the canal it was not found possible at that 
time to determine satisfactorily whether the disease had commenced in that 
region or in the middle ear. In the course of a few days the swelling ex- 
tended outward from the canal, and involved the auricle, causing it to be- 
come very much thickened. An incision made in the swelling gave exit 
only to a thin, serous fluid. An opening in front of the meatus and just 
below the tragus afterward formed, from which the discharge was more 
purulent in character. On the 1st of September, when Dr. Pomeroy first 
saw the patient, a large abscess occupied the region of the fossa conchse, 
and extended upward, downward, and backward, involving at least half 
the area of the auricle. In front of the meatus, near the tragus was a 
circumscribed swelling, with a fistulous opening in its apex. The large 
tumor was somewhat nodulated, but fluctuation was easily recognized 
throughout, both in front and behind. An incision was made posteriorly, 
where the wall of the abscess was very thin, and about five drachms of 
pus were evacuated. On exploration with the finger, it was found that 
the cavity of the abscess was bounded, both in front and behind, by in- 
tegument and connective tissue only, the cartilage having entirely dis- 
appeared from the region involved. At subsequent times small abscesses 
made their appearance in other localities, viz.: in the region of the lobule, 
three ; in the tragus, one ; in the upper portion of the helix, two. The \ 
larger cavity closed in three weeks without special treatment, beyond a 
thorough daily cleansing with tepid water. The discharge from the abscess 
in the helix was somewhat glairy in character. Early in November the 

1 This case is reported in detail in the Transactions of the American Otological So- 
ciety for the year 1875. 



DISEASES OF THE EAE. 



47 



last abscess healed, but the auricle remained in a very greatly deformed 
state. 

This case, when studied in the light of Meyer's and Pollak's investiga- 
tions, adds strength, it seems to me, to the theory that othsematoinata owe 
their origin primarily to a softening of the cartilage in spots. An intercur- 
rent acute inflammation of the skin, or of the perichondrium at some one 
spot, may be required to fan these smouldering fires into a rapidly destruc- 
tive conflagration, such as that observed in the present instance ; but, 
without the predisposition supplied by the existence of several centres of 
softening in different parts of the cartilage, it is difficult to understand how 
an inflammation, beginning in the middle ear or external anditoiy canal, 
and extending to the auricle, should result in such serious damage to the 
cartilaginous framework. 

"Wendt, 1 under the heading, " A Case of Subacute Inflammation of the 
Cellular Tissue of the Auricle," describes a case which corresponds in all 
essential particulars with the one just narrated. With this exception, I can 
find no other case on record in which the extent of the destruction of the 
cartilage and the degree of the deformity resulting therefrom were so great 
as in Dr. Pomeroy's case. 

The case reported by Dr. Roosa, under the title of " Deformity of the 
Auricle, resulting from Inflammation of the External Auditory Canal," seems 
to me to belong properly to this category. 2 The subject is one of such im- 
portance that I make no apology for giving somewhat in detail the histoiy 
of this case. 

The patient, a female, forty years of age, consulted Dr. J. Ome Green, of 
Boston, on the 13th of November, 1871. She was then suffering from a 
diffuse inflammation of the meatus, of one week's standing. " The swelling 
was greatest about the middle of the meatus, closing the passage there. 
There was not much swelling externally. During that week she had a 
furuncle on one eyelid, and when seen was suffering froin inflammation of 
one ala of the nose." As the application of poultices failed to reduce the 
swelling, Dr. Green made an incision nearly the whole length of the meatus. 
This evacuated a little pus and relieved the pain. Three or four days later 
the ear began to swell again, and all the old symptoms returned. Another 
thorough incision was made, evacuating a little pus and causing slight re- 
lief. On the 22d of December — that is, several days after the last incision 
had been made — she came under Dr. Roosa' s care. The auricle, which had 
in the meantime been poulticed a great deal, presented a somewhat red- 
dened appearance. The whole meatus was occluded by a fungous growth 
springing from the middle of the anterior wall of the auditory canal. Dr. 



1 Archiv f iir Ohrenheilkunde, Bd. III. , S. 30. 

2 Transactions of the American Otological Society, 181 
woodcut of the deformed auricle). 



p. 123 (with an excellent 



48 DIAGNOSIS AND TEEATMENT OF 

Roosa removed this by a snare, applied nitric acid to the base, and ordered 
the warm douche to be continued. The patient's general condition was 
not good. Tonics were continued. As the fungous growth still persisted 
in sprouting after its removal, Dr. R. found it necessary to remove portions 
of it from time to time. Toward the end of January the whole auricle be- 
came very red, swollen, and tender. Fluctuation could be felt in different 
parts, and especially in the concha. Incisions were made at different times 
into these fluctuating swellings. A bloody serum was evacuated, but no 
pus. " On February 12th the canal had thoroughly healed, but the auricle 
was still swelled, red, painful, and tender, and the natural features of the 
part, except the helix, were removed by this swelling, so that the ear was 
considerably deformed. The meatus was but a minute opening, but when 
the walls were drawn apart the hearing was found to be unimpaired. The 
membrana tympani was never affected during the whole course of the trou- 
ble." The patient returned to Boston at this time, and was under the care 
of Dr. Henry L. Shaw. The swelling of the auricle increased, and at dif- 
ferent times incisions were made, and pus was evacuated. All active inflam- 
matory symptoms did not cease until during the following April or May. 

Dr. Lucien Howe, of Buffalo, has recently reported a case, which may 
possibly belong in this same category. 1 The degree of deformity observed 
in this case, and caused, as Dr. Howe believes, by a chronic purulent in- 
flammation of the middle ear, is so slight that, when examined by itself, 
the auricle presents simply a somewhat peculiar appearance. When, how- 
ever, it is compared with the auricle of the opposite side, where the middle 
ear shows no evidences of ever having been the seat of a chronic purulent 
inflammation, the deformity is seen to be quite marked. In the first place, 
the auricle, as a whole, is considerably smaller than its fellow ; and, in the 
next place, the fossa conchse is noticeably contracted and also more or less 
distorted in its outlines. It is a very common experience, in cases of chronic 
purulent inflammation of the middle ear, to find the external auditory canal 
greatly diminished in size from protracted inflammation of its walls, but I 
cannot recall a single case in which the auricle had become, through simi- 
lar causes, so deformed as to attract my notice, and so lead me to compare 
it with its fellow. It is quite possible that in cases where pus is discharged 
for weeks and months at a time over the walls of the cartilaginous meatus, 
over the posterior aspect of the tragus, into the fossa conchse, and through 
the incisura intertragica, a chronic subacute perichondritis may be kindled 
and kept up until a considerable amount of cicatricial tissue is produced. 
As the tendency of this newly formed tissue is to contract powerfully, it is 
easy to understand how, in course of time, the auricle may become notice- 
ably diminished in size and otherwise twisted out of shape. But how are 
we to distinguish these cases with certainty from those in which the de- 

1 Buffalo Medical and Surgical Journal, Dec, 1879. 



. 



DISEASES OF THE EAR. 49 

formity owes its origin to an attack of chondroinalacosis ? This latter dis- 
ease may perfectly well ran its course contemporaneously with a chronic 
otitis media puralenta ; in fact it is not unlikely that the irritation pro- 
duced in the canal and vicinity by the stream of more or less acrid pus 
which flows over it, may even fan into activity an otherwise latent chondro- 
inalacosis. A careful inquiry into the past history of cases .like that which 
Dr. Howe has reported may in time solve some of these questions which 
now must await a solution until our store of facts has become larger. 1 

Diagnosis. — Perichondritis of the auricle presents, in its acute stage, 
such salient features that no physician would be likely to mistake it for any 
other form of disease. The conditions presented are practically those of 
an abscess, generally of large size ; but the abscess has peculiar anatomical 
relations, and its contents are usually different from those of an ordinary ab- 
scess. Thus, we find, after an incision has been made, that the cartilage forms 
one wall of the abscess, and the perichondrium the other. We also find that 
the contents of this abscess are composed, not of thick, healthy pus, such as 
is usually found in acutely formed abscesses, but of a glairy yellowish fluid, 
or of a bloody serum, or partly of thick pus, and partly of thin, yellowish 
serum. From the external appearance alone it is impossible to decide 
whether the abscess owes its origin to a burn, to a frost-bite, to a blow upon 
the ear, or to nutritive changes in the cartilage or perichondrium. 

If, in addition to the perichondritis, softening processes are going on in 
the subjacent cartilage, the combined destructive and proliferative changes 
may give to the auricle such a knobbed and distorted appearance as to sug- 
gest the presence of cancer. In Dr. Pomeroy's case I frankly confess that 
I leaned more decidedly toward the diagnosis of epithelioma of the auricle 
than toward that of a chronic inflammation of the perichondrium. I had re- 
cently had under my care a well-marked case of epithelioma of the auricle, and 
the outward resemblance between that case and the one I have just referred 
to was so strong that I could not help being struck with it. Besides, I had 
never before seen a case of chondromalacosis, and was not aware that it 
could produce such extensive destruction of the cartilage in one part of the 
ear, and such marked hypertrophy of the perichondrium in another. On 
closer examination, however, an appreciable difference between the two con- 
ditions can be made out even with the naked eye. In cancer, for instance, 
the skin will be found to have lost its suppleness, and to be rough and un- 
even on its surface ; while in chondromalacosis the skin is either smooth or 
is capable of being made smooth by stretching, and it can readily be shown 
that the un evenness of surface is due to the unevenness of the subjacent 

1 From a very superficial examination of the literature I find that three cases of 
othematoma, in mentally sound persons, have been reported in addition to those al- 
ready mentioned, viz., one by Schwartze (Arch. f. Ohrenh., Bd. II., S. 213), in which 
a blow upon the ear was the exciting cause ; and two by Brunner (Op. cit., Bd. V., S. 
26) , in one of which a frost-bite was the exciting cause. 
4 



50 DIAGNOSIS AND TREATMENT OF 

parts rather than to any changes in the skin itself. As a matter of course, 
a microscopic examination of the suspected tissues would set at rest all 
doubts about the correctness of the diagnosis. 

Prognosis. — The prognosis in this class of cases has reference simply to 
the degree of deformity which is likely to result from the disease. In sim- 
ple perichondritis the prognosis is good. If the abscess is opened early 
and freely, very little, if any, deformity will be left after the parts have healed. 
In chondromalacosis the degree of permanent deformity will depend chiefly 
upon the extent of cartilage destroyed, and only to a slight degree upon the 
inflammatory thickening of the perichondrium. 

Treatment. — Cases of perichondritis or of chondromalacosis of the auricle 
rarely come into the physician's hands until a distinct cavity, with fluid con- 
tents, has formed. The most urgent indication in this stage of the disease 
is to relieve the tension and prevent further separation of the perichondrium 
from the cartilage. This can best be accomplished by making an incision 
into the swelling ; not a small one, which will allow only the fluid portions 
of the contents to escape, but a liberal one, that will afford ample room for 
the thorough daily cleansing of the cavity. If the cartilage seems to be in 
a healthy condition, we may begin at once, on the day following the inci- 
sion, to bring moderate pressure to bear upon the separated cartilage and 
perichondrium, in hope of thus hastening their union by adhesion. For 
this purpose Dr. Hickok's contrivance, described on p. 43, will be found very- 
useful ; or two pads may be adjusted, one in front of and the other behind 
the auricle, and a bandage may then be passed over the top of the head and 
under the chin, in such a manner as to keep the pads in position and exert 
moderate pressure upon the walls of the cavity. In addition to the daily 
cleansing of the cavity with tepid water, and the readjustment of the pads 
and bandage, it is doubtful whether we can do anything that will materially 
hasten the process of healing. My own preferences would lead me to mop 
out the cavity with tincture of iodine after each cleansing, but I cannot say 
positively that this procedure materially hastens recovery. Instead of the 
simple tincture, the compound tincture of iodine may perhaps be used with 
equal advantage. In cases of chondromalacosis it would probably be better 
to omit making pressure until we are confident that the processes of soft- 
ening have come to an end. If new collections of fluid form in other parts 
of the auricle, these must each be treated separately, in exactly the same 
manner as the original collection. 

Probably in a majority of these cases, it will be found desirable to pre- 
scribe quinine, iron, and a more liberal diet. It is unnecessary, however, 
for me to enter any more fully into this aspect of the subject. 



DISEASES OF THE EAR. 51 



New-Growths. 



Fibroid tumors of the auricle are observed quite frequently among ne- 
gresses, and occasionally among white women, as a result of the operation 
of piercing the lobule, or of the irritation caused by wearing an ear-ring. 
Through the kindness of my colleagues I have had the opportunity of ex- 
amining two or three cases of this form of new-growth, but I have never 
had a case under my immediate care. The tendency to recur, after appar- 
ently complete extirpation with the knife, is perhaps the most interesting 
feature connected with these growths. In one of the cases referred to above, 
the extirpated tumor— the second or third return of the growth— was placed 
in my hands for microscopic examination. To my surprise, the most care- 
ful search failed to discover cellular elements in any part of the mass, which 
was as large as a hickory-nut and slightly lobulated in structure. The 
growth seemed to be made up entirely of fibrous tissue, which appeared 
under the microscope in the form of wavy bands. 1 

Next to the fibroma, epithelioma is probably the commonest form of 
new-growth observed in the auricle. The following is the only case of this 
nature that has come under my observation. The patient, a coachman, 
forty-three years of age, and otherwise in excellent health, presented him- 
self at the Infirmary with an auricle which, at first sight, seemed to be 
affected with eczema. The larger part of the upper half of the auricle 
presented, on its anterior aspect, an almost continuous mass of scabs. On 
the posterior surface there was also one moderately large scab. Between 
these crusts, and surrounding them, the skin presented a bright red and 
infiltrated appearance, with quite sharply defined limits at the points where 
it merged into the surrounding healthy skin. After the scabs had been 
removed, it was found that they covered quite deep ulcers. At one spot, 
corresponding to the location of the crust on the posterior aspect of the 
auricle, the cartilage was completely destroyed, and a mop of cotton-wool, at 
least four millimetres in diameter, could readily be passed through the open- 
ing from one side to the other. The orifice of the external auditory canal 
was not involved. The patient gave the following history of the development 
of the disease : During the previous winter his right auricle had been 
frost-bitten, and the affected portion had subsequently remained quite sore. 
Different plans of treatment had been tried, but the area of soreness 
had steadily increased despite all treatment. As the neighboring glands 



1 Cases of fibroid tumor of the auricle have been reported by Bertolet (Trans. Araer. 
Otol. Soc., 1871), Clarence J. Blake (Arch. Ophth. and Otol., Vol. III., No. 1, p. 87), 
Burnett (Treatise on the Ear), and others. A very interesting case of myxofibroma of 
the auricle is reported by Dr. C. R. Agnew, in the Transactions of the American Otol. 
Soc. for 1878. In this case the tumor returned four times after the original operation. 



52 DIAGNOSIS AND TREATMENT OF 

were not enlarged, I thought the progress of the disease might be arrested, 
or at least be retarded, by excising the diseased portions of the auricle. 
The patient's consent having readily been obtained, he was etherized, and, 
while he was under the influence of the anaesthetic, a V-shaped piece, in- 
cluding the diseased tissues, was excised by means of a strong pair of 
scissors. The remaining upper and lower portions of the auricle were then 
fitted to each other as neatly as possible, and held in coaptation by means 
of several very fine interrupted sutures. The wound healed promptly, but 
very soon afterward fresh evidences of the disease manifested themselves 
along the line of the cicatrix, showing quite clearly that all the diseased 
tissues had not been excised. In 1877 I heard that the man was still alive, 
but could learn no particulars with regard to the condition of the affected 
auricle. 

The case reported by Dr. J. Orne Green, of Boston, 1 resembles, in all 
essential particulars, the one which I have just described. In his case, 
however, the disease had made further progress, and complete amputation 
of the auricle and cartilaginous portion of the meatus was found necessary. 
Koosa, 2 and Burnett 3 each report a case, and the latter gives full reference 
to the literature of the subject. 

In 1871, at the meeting of the American Otological Society, I reported 
a case of coma humanum* of the auricle. The details of this case are as 
follows : The patient, a man fifty-five years of age, and in good general 
condition, stated that nearly two years previously he 
first noticed a small sharp point on the top of the ear. 
He picked it constantly with his nails, until it became 
sore. At the same time he noticed that what he sup- 
posed to be a simple scab covering the spot, grew to 
be quite thick, hard, and prominent. Whenever it 
reached such a size as to be an object of disfigure- 
ment, he was in the habit of paring it down with a 
razor. During the past two months it had grown, he 
thought, rather more rapidly than before, and he was 
numo G f theTuride? ^^ therefore anxious to have it removed. 

At the time when he visited me the growth pre- 
sented the following appearances : a blunted, hom-like protuberance, three- 
fourths of an inch long and nearly as broad at its base, springs from the 
upper and posterior portion of the left helix. Of a whitish color at its base, 
it gradually grows quite smoky at its summit, which is more or less jagged 
in appearance. It is distinctly striated, the markings running in a slightly 



1 Transactions of the American Otological Society, 1870. 
a Treatise on the Diseases of the Ear. New York, 1873. 

3 Treatise on the Ear. Philadelphia, 1877. 

4 See Rindfleisch : Pathologische Gewebelehre, Leipzig, 1866. § 293. 




DISEASES OF THE EAR. 53 

divergent direction from the summit to the base. At the extremity, and 
in the middle portion it is hard like horn, but near the base it can easily 
be compressed, though yet comparatively hard. The line of demarcation 
between the growth and the normal skin is very abrupt. There is no ten- 
derness on pressure. 

The patient having been brought under the influence of ether, I made 
two converging incisions on either side of the base of the tumor. The 
tissues included between these incisions comprised every trace of the new- 
growth, and the wedge-shaped wound which remained was obliterated by 
approximating the opposite edges of skin and keeping them in close appo- 
sition by means of fine interrupted sutures. Union took place by granu- 
lation, and at the end of the third week scarcely a trace of the operation 
co aid be detected. Six months later the patient was seen again. There 
were no signs of a return of the growth. A small, sharp point, however — 
similar, he says, to the one first noticed on the ear — could be distinctly felt 
and seen on the outer surface of the left eyelid. 



Miscellaneous Diseases. 

I have never seen a case of herpes zoster of the auricle, and must refer 
the reader, for information upon this topic, to a monograph by Gruber, l 
to a paper by J. Orne Green, on " Neuralgia in and about the Ear," 2 and to 
Burnett's " Treatise on the Ear." I have also never seen a case of lupus of the 
auricle. Strawbridge, 3 of Philadelphia, reports one case of the disease, and 
Neumann 4 makes the statement that the auricle is the favorite seat of lu- 
pus. 

Syphilitic gummata and syphilitic ulcerations are occasionally seen on the 
auricle. The following two cases are the only ones that have come un- 
der my personal observation : — 

First case. Male, setat. 26. May 27, 1874. Syphilis (primary) four 
years ago. Sore throat and eruption on face last December. Three weeks 
ago he began to have some pain in the left ear, without tinnitus or notice- 
able deafness. During the past week the pain has been more pronounced, 
and there has been a slight discharge from the outer canal. Tragus and 
outer portion of meatus red, swollen, and tender, especially superiorly. 
Deep ulceration of the auricle at the commencement of the helix just 



1 Die Blaschenflechte am Ohre. Monatsschrift fiir Ohrenheilkunde, IX., 5, May, 
1675. 

2 Transactions of the American Ofcological Society, 1874. 

3 Ibid. , 1878. 

4 Monatsschrift fiir Ohrenh. III., 5, May, 1869. 



54 DIAGNOSIS AKD TREATMENT OF 

above the orifice of the external auditory canal. It measures fully half an 
inch in diameter, and extends down to the cartilage. 

The ulcer was cauterized with the stick of nitrate of silver, and three 
leeches were applied in front of the tragus. (Patient did not return.) 

Second case. Male, setat. 32, in rather poor physical condition, June 
16, 1875. He is now suffering from syphilitic disease of the nasal bones 
or cartilages, the contour of the nose being already disfigured. A large 
part of the fossa conchse of the auricle is occupied by a dry scab, from 
beneath one edge of which a little pus escapes. The removal of this scab 
brought to view a roundish ulcer about the size of a three-cent piece. The 
ulcerated surface, which was not depressed below the surrounding surface 
of healthy skin, seemed to be composed of a soft, succulent tissue, in places 
apparently papilliform in structure. A single application of a saturated 
solution of nitrate of silver caused the ulcer to heal entirely in the course 
of a few days. It should be stated, however, that the patient had been 
taking iodide of potassium for some time previously. 

Chimani reports an interesting case of cirsoid aneurism of the auricle, 
involving the branches of the superior, anterior inferior, and posterior au- 
ricular arteries. 1 A somewhat similar case is reported by Weinlechner. 2 
Repeated injections of a solution of the chloride of iron accomplished a 
complete cure in the former case, but in the latter it was found necessary 
to ligate the carotid artery. 

In both of these cases a dilatation and perhaps lengthening of existing 
arterial vessels constituted the chief feature of the disease, while in the case 
of " angioma cavernosum " reported by Kipp, 3 an actual new-growth of 
blood-vessels appears to have taken place. The case of an " erectile tu- 
mor " of the auricle, reported by Martin, 4 and referred to by Schwartze, 6 
was probably of the same nature as that observed by Kipp. 

Cleft lobule, due to the wearing of ear-rings, is a comparatively common 
deformity of the auricle. I have several times seen a double cleft, but 
have never observed either the single or the double cleft in a patient who 
considered the deformity sufficiently great to impel her to have it reme- 
died by an operation. 

It would seem as if wounds and contusions of the auricle ought to come 
under the aural surgeon's observation quite frequently, especially in a large 
city like New York. As a matter of fact, I have seen but one case of this 
kind. Furthermore, on looking over the last annual report (1878) of the 



1 Archivf. Ohrenheilkunde, Bd. VIII., S. 62. 

2 Monatsschrif t f . Ohrenheilkunde, XI., 1877. 

3 Transactions of the American Otological Society, 1875. 

4 Gazette des hopitaux, 102, 1857. 

6 Archivf. Ohrenheilkunde, I., S. 237. 



DISEASES OF THE EAK. 00 

New York Eye and Ear Infirmary, I find that out of a total of nearly 2,800 
cases of ear disease, there was but one case of lacerated wound of the 
auricle ; from which I infer that traumatic disease of this part of the 
body is quite rare. In the single case which came under my observa- 
tion, the patient, a strong, healthy woman, had fallen in such a manner 
as to strike heavily with the side of her head upon the sharp edge of a 
tin pail, which was standing upon the floor. She was probably intoxica- 
ted at the time. After she had risen to her feet, she discovered that the 
lower part of the ear (the entire lobule and the lower portion of the helix) 
had been almost severed from the head. When she appeared at the 
Infirmary, three days after the accident had happened, the lobule was 
found to be hanging loosely suspended by a small band of flesh. The raw 
surfaces had begun to suppurate, but there was very little redness or swell- 
ing of the adjacent parts. At the suggestion of my colleague, Dr. J. N. 
Beekman, the raw surfaces were kept in close apposition by means of a 
series of delicate supporting loops or bands of frayed lint held fast by a 
coating of collodion. By this device the edges of the wound were brought 
together in as perfect a manner as if a series of fine sutures had been used. 
The extreme posterior end of the wound was left open for drainage pur- 
poses. When the patient returned to the Infirmary, exactly one week later, 
the dressings were found to be still firmly in position, and the parts pre- 
sented every appearance of having practically united by first intention ; at 
all events, there was no evidence that further suppuration had taken place. 
To ensure thoroughly firm union, the patient was instructed to wait three 
or four days more before removing the dressings. As she did not return 
a third time, it is fair to infer that the cure proved successful. 

Congenital Malformations. 

Only three cases of congenital malformation of the auricle have come 
under my personal observation. In the first case (a young infant of the 
female sex), both ears were deformed, though in a very different degree. 
The right auricle was perfect in all its parts, but just in front of the tragus, 
and perhaps continuous with its cartilaginous framework, was a loosely at- 
tached, irregular mass, which might perhaps be considered as a supernumer- 
ary tragus. It consisted of three distinct lobes, of which the central one was 
considerably larger than the other two. The external auditory canal was nor- 
mal. The left auricle was represented by a small, irregularly shaped, flat- 
tened mass, which bore no resemblance whatever to a normal auricle. Very 
nearly in the centre of this mass, externally, there was a small depression, 
which ended in a cul-de-sac at a depth of three or four millimetres. Beyond 
the depression, I could feel a short, solid cord, representing undoubtedly 
the obliterated or imperfectly developed external auditory canal. In all 
other respects, the child seemed to be perfectly formed and well nourished. 



56 DIAGNOSIS AND TREATMENT. 

In the second case (female child, nearly three years old), the malforma- 
tions of the auricles were exactly the same on both sides. The lobe was 
perfectly formed and of full size, but the upper parts of the auricle seemed 
to be shrivelled up into a small shapeless mass. As in the previous case, a 
small depression indicated the situation of the rudimentary external audi- 
tory canal. With the finger the tympanic ring could readily be outlined ; 
it appeared to be of normal size. The parents were positive that the child 
heard quite well. I was not able myself to determine satisfactorily what 
degree of hearing she possessed. Apart from the deformities described 
above, the child appeared to be perfectly formed. 

Finally, in the third case, the deformity consisted in an imperfectly de- 
veloped cartilaginous framework of the auricle. The child, a twin, four 
years old, and otherwise well developed, possessed two large, but very thin, 
auricles. The fossa helicis of each ear was obliterated, and the upper part 
of the auricle drooped, somewhat after the fashion of a dog's ear. The 
changes noted were more marked on the left than on the right side. The 
impression made upon my mind at the time was that undue pressure in 
utero had flattened both auricles, and had arrested the development of their 
cartilaginous frameworks. 1 

1 Dr. C. J. Blake reports an interesting case of congenital malformation of the auri- 
cle, in the Archives of Ophthalmology and Otology, Vol. III., No. 1, p. 86. Straw- 
bridge reports a case in the Transactions of the American Otological Society, for 1875, 
and gives some references to the literature of the subject. Dr. Knapp also reports a 
case in the Transactions of the American Otological Society, for 1870. Further refer- 
ences to the literature of the subject will be found in the treatises of Roosa and Bur- 
nett. 



CHAPTEK IV. 

DISEASES OF THE EXTERNAL AUDITORY CANAL. 

The diseases to which this portion of the ear is liable comprise those 
which affect the auricle, and others which are peculiar to the canal itself. 
By far the commonest of these is, 



Impacted Cerumen. 

In the cartilaginous portion of the external auditory canal, and also, to 
a very limited extent, in the osseous portion, there are glands which secrete 
the peculiar substance known as cerumen, or ear-wax. These glands, when 
examined under the microscope, in thin sections of the meatus, are seen to 
be similar in all respects to the sweat-glands. The secretion from these glands 
is a transparent yellowish fluid. It is only after exposure to the air that it 
gradually becomes inspissated and of a darker color. Under certain condi- 
tions the ceruminous glands secrete this yellowish fluid in such abundance 
that it escapes from the orifice of the external auditory canal in the form of 
a watery discharge. I have several times been told by patients that they 
had a discharge from the ear, and, on making an examination, have been 
surprised to find that what both they and I supposed to be a bona fide dis- 
charge of pus or sero-pus, was in reality simply an excessive secretion of 
fluid cerumen. As a rule, however, the rate of secretion is so slow that 
the cerumen becomes inspissated very soon after it leaves the mouth of the 
gland. For the further propulsion of this material out of the canal, Nature 
seems to have made a very curious provision. It is now an established fact 
that at least the uppermost layer of the epithelium lining the external audi- 
tory canal moves constantly from within outward. Thus, for example, if 
on a certain day we find a scab resting wholly upon the drum-membrane, 
five or six days from that time we shall find it resting partly upon the drum- 
membrane, and partly upon the wall of the osseous canal. At the end of 
another week it will be found to have travelled outward entirely beyond 
the limits of the membrana tympani. This same surface movement un- 
doubtedly takes place symmetrically throughout the entire length of the 
canal, and -supplies the force required to extrude all ordinary accumulations 






58 DIAGNOSIS AND TREATMENT OF 

of cerumen. In the Eustachian tube and in the bronchial tubes we find 
the epithelial cells provided with cilia which constantly vibrate in such a 
manner as to propel any mucus or foreign substance that may happen to be 
in the tube, in the direction of the naso-pharyngeal space or of the larynx* 
as the case may be. The conditions that exist in the external auditory 
canal do not require any such vigorous propelling power as that supplied 
by the movement of the cilia in the other channels mentioned, and, accord- 
ingly, Nature supplies a less active power, but, at the same time, one that 
is better adapted to stand the rough usage to which this part of the body 
is specially liable. 

It is not an easy task to harmonize the existence of such an extruding 
power in the walls of the external auditory canal with the extremely fre- 
quent occurrence of the condition known as impacted cerumen. An ab- 
normal activity on the part of the ceruminous glands is undoubtedly the 
most important factor in the production of this condition. At the same 
time hypersecretion alone can hardly be held responsible for the produc- 
tion of the impacted state ; other factors must certainly aid in producing 
it. The sharp bend which the canal makes near the external orifice is often 
associated with such a marked shortening of one of its diameters that for 
all intents and purposes the canal is very much narrower at this point than 
it is a short distance deeper in, where the larger part of the cerumen is 
secreted. This narrowing of the canal varies greatly in different individ- 
uals, and in some no narrowing whatever is found. Where it exists, one 
can easily conceive how it may prevent a mass of cerumen, of comparatively 
small size, from being extruded from the canal. "When the mass has once 
been arrested in its movement outward, there is no difficulty in understand- 
ing how it may grow, by accretions upon its surface, to the full size of the 
cavity which contains it. Furthermore, it is not unlikely that the individ- 
ual's own efforts to keep the orifice of the external auditory canal clean, or 
to relieve the sensation of itching which is so often present in this condi- 
tion, sometimes result in pushing the accumulation farther inward toward 
the drum-membrane. 

Excessive secretion of cerumen is so often associated with naso-pharyn- 
geal catarrh that it is hard to resist the belief that the former is a reflex 
phenomenon dependent upon the latter. On the other hand, in certain 
cases of well-marked deafness, it is a common experience to hear the pa- 
tients say, — of their own motion, and not in response to a question, — that 
they never find wax in their ears, and have not for several months or years 
past. The few cases that I have examined, since my attention was attracted 
to the coincidence of deafness with absence of the secretion of cerumen, 
presented the following conditions : — The membrana tympani was unusu- 
ally thin and translucent, though not appreciably sunken ; through its pos- 
terior half could be seen the darkly shaded niche of the fenestra rotunda, 
and, above this, perhaps also the faint outlines of the long process of the 



DISEASES OE THE EAR. 59 

anvil. The whiteness of the promontory was also easily recognized through 
the membrane. On inspection of the pharynx the mucous membrane of 
this region was found to be pale and very thin ; apparently the follicles had 
all disappeared through atrophy. As I shall have occasion to speak of these 
conditions again farther on, it is not necessary to enter more minutely into 
details in this place. If it be once admitted that increased functional ac- 
tivity of the pharyngeal glandular elements may in a reflex manner increase 
the functional activity of the ceruminous glands, the question at once sug- 
gests itself, Why may not the subsequent atrophy of the pharyngeal glands 
bring about, in the same reflex manner, a wasting of the glands in the ex- 
ternal auditory canal ? Is it not also by a reflex process that organic dis- 
ease is set up in one eye by disease already existing in the fellow eye ? It 
would of course be premature to express any positive opinion with regard 
to the relations here suggested. Further facts, both clinical and patho- 
logico-anatomical, are needed, before we can be sure, first, that the rela- 
tions described above are not exceptional, and, second, that the absence of 
cerumen in the auditor)- canal is really due to a wasting of the glands 
which produce it. 1 

Symptomatology. — During the formation of the mass, before it has 
reached such a size as to occlude the canal, the patient, as a rule, experi- 
ences no symptoms which would be likely to call his attention to the ear. 
In cases, however, where the canal is slit-shaped, a sense of fulness or dis- 
comfort may be experienced long before the canal is actually occluded, — 
that is, as soon as the accumulation is large enough to bridge the space be- 
tween the opposite walls. Complete occlusion may take place so gradually 
that the patient's attention is attracted to only one symptom, viz., the gradual 



1 Some time after the above had been written, I discovered a paragraph in an arti- 
cle by Dr. O. D. Pomeroy, of this city (Trans, of the Amer. Otol. Society for 1S73. 
Article on an Examination of 100 Cases of Impacted Cerumen, etc.), in which the 
writer expresses in part the same view as that which I have just stated. His words 
are : " In view of the fact that frequently an absence of a normal amount of cerumen 
is observed in old cases of aural catarrh, it may, together with the present observa- 
tions, cause one to infer that the ceruminous function is greatly affected in catarrhal 
diseases. 

1 ' Perhaps a theory of this kind may sometimes be borne out by a sufficient number 
of facts ; that the earlier stages of catarrh result in hyperemia, and consequently aug- 
mented function of the ceruminous glands, which, continued, may result in atrophy, 
with abolition of function, precisely as results in inflammations of the mucous mem- 
brane lining the fauces, etc." 

It is perhaps more in accordance with established facts to consider atrophy — as 
the natural termination of the prolonged increased functional activity of the ceruminous 
glands, than to consider it as the result of reflex influences. With regard, however, to 
the first step in this series of changes, I should rather favor the view which refers its 
origin to a reflex influence, than that which makes the irritation spread directly from, 
the mucous membrane of the middle ear to the skin of the external auditorv canal. 



GO DIAGNOSIS AND TREATMENT OF 

diminution of the hearing. In very many cases, however, the statement is 
made that the diminution in the hearing came on quite suddenly, as, for 
instance, after a bath, after washing the head, or after some mechanical in- 
terference with the ear (introduction of the end of a towel, etc.). This sud- 
den diminution of the hearing may then pass away as suddenly as it came, 
to return again after the lapse of a few days or weeks. When the canal has 
become fairly occluded, other symptoms may develop. In a few cases there 
will be tinnitus, which may be ascribed to pressure exerted by the ceru- 
minous mass upon the drum-membrane, or possibly to the obstruction of 
the venous circulation in the external auditory canal, thus causing a passive 
congestion of the veins of the middle ear, which pour their contents in part 
into those of the meatus. In any given case, however, it is nearly if not 
quite impossible to determine what share the ceruminous mass, and what 
the coexisting catarrhal inflammation of the middle ear, take in producing 
this symptom. Pain can hardly be mentioned among the symptoms of this 
condition, as it is due to an intercurrent inflammation of the walls of the 
canal. Cases are on record which seem to show that impacted cerumen 
may produce, in a reflex manner, epileptiform convulsions. I have also re- 
cently read of a case in which a chronic bronchial catarrh seemed either to 
owe its origin to, or to be kept up by, the presence of a mass of impacted 
cerumen in the patient's auditory canal. 1 At all events, the removal of the 
mass caused the cough and expectoration to cease in a very short time. 
Furthermore, cases have been reported in which a high degree of dilatation 
of the osseous canal is ascribed to the pressure of a mass of cerumen. I 
believe that cases have also been reported in which even a fatal issue has 
been referred back to the gradual increase in size of a mass of impacted 
cerumen. My impression is, that if all these cases could be carefully an- 
alyzed, the great majority of them would be found to be in reality cases of 
desquamative inflammation of the canal, or of otitis media purulenta, with 
hardening of the purulent secretion in the meatus. Inspissated cerumen 
forms on the outer side of, and becomes mingled with, these purulent and 
epidermal products, and so the cases come to be classified among those of 
impacted cerumen. While it may not be possible in all cases to draw a 
sharp line of distinction between the milder cases of desquamative inflam- 
mation of the canal, and those of inspissated cerumen, it is of decided 
practical importance to make the distinction whenever we can. So far as 
my own experience goes, I may say that I have never seen a case in which 
the pressure made by a mass of impacted cerumen has caused absorption 
of the bone and consequent increase in size of the canal. Nor have I ever 
seen one in which bronchial catarrh, epileptiform convulsions, or any other 
equally grave symptoms could fairly be attributed to impacted cerumen, 

1 The case is reported in either the British Medical Journal or the London Lancet, 
in one of the November numbers (1879). 



DISEASES OF THE EAR. 61 

in the strict sense of the terra. Tinnitus and moderate dizziness, due prob- 
ably to the pressure of the mass upon the drum-membrane, are certainly 
not rare symptoms, but I have never seen a case in which the impacted 
cerumen had produced actual fainting or loss of consciousness. 

Diagnosis. — Inspection with the speculum and reflected light reveals 
the presence, in typical cases, of a black or dark brown mass, filling the 
canal, and obstructing the view of the deeper parts. Until the contents of 
the canal have been thoroughly removed, it is not safe to say positively 
that the case is simply one of impacted cerumen. All sorts of conditions 
may be found beyond the outer mass or shell of cerumen, and the physician 
must therefore withhold or modify his diagnosis until he can ascertain fully 
the true state of the ear. 

Prognosis. — In cases of impacted cerumen, associated with difficulty of 
hearing, the physician will do well to express his opinion very guardedly 
with regard to the question of restoration of the hearing-power. It is such 
a common experience, as I have already stated, to find a chronic naso- 
pharyngeal and middle ear catarrh associated with impacted cerumen, that 
he should always be prepared to find that the catarrhal affection and not 
the obstructing mass, has diminished the acuteness of the hearing. The 
marked tendency to relapses must also not be forgotten, when a prognosis 
is given. 

Treatment. — The question of treatment resolves itself practically into 
the question, How can the obstructing mass be removed most thoroughly, 
quickly, and pleasantly — both for the patient and for the physician ? In 
the earlier period of my practice I pursued the orthodox plan of employing 
the syringe and warm water for this purpose. Little by little, however, I 
became satisfied that in the great majority of cases the removal of the mass 
could be effected much more quickly and pleasantly by the use of the cu- 
rettes, the cotton-holder, and the angular forceps, than by any other plan. 
Accordingly, during the past eight or nine years it has been my uniform 
practice to use the syringe only in certain exceptional cases, for instance, 
in those in which, after the removal of the greater part of the mass by in- 
strumental means, a semifluid or very tenacious cerumen was found plas- 
tered over the drum-membrane ; and also in those in which the extreme 
smallness of the canal rendered it unusually difficult to follow the move- 
ments of the curette with the eye. The objection raised by some authors 
against the instrumental plan of removing impacted cerumen, viz., that it 
requires great skill, and may prove highly dangerous in unskilful hands, 
does not seem to me to be a valid one. Therapeutic methods should be 
recommended in accordance with their absolute merits, and not because 
they will be likely to prove the least harmful in unskilled or clumsy hands. 
The merits of the instrumental plan have already been alluded to, but I will 
repeat them here. In the first place, when a case of impacted cerumen 
presents itself for the first time, we cannot say positively what is the condi- 



62 DIAGNOSIS AND TKEATMENT OF 

tion of the membrana tympani and deeper portions of the canal. The con- 
ditions may be such as to contraindicate the introduction of a stream of 
water. This risk, which is entirely avoided by the instrumental plan, must 
be incurred by those who make a practice of employing the syringe. In 
the second place, in a large number of cases, the instrumental plan will ac- 
complish in ten or fifteen minutes what the most skilful employment of the 
syringe cannot possibly accomplish in even an hour's time. In the third 
place, it is easily possible for a man with average manual skill to acquire 
such dexterity in the manipulation of the curette, and the other instruments 
mentioned, that he will be able to remove impacted cerumen from the au- 
ditory canal with less discomfort to the patient than is usually experienced 
when the syringe is used. I base this statement upon my experience as a 
clinical instructor ; many of my pupils having, in a comparatively short 
time, acquired the power to accomplish this task successfully. Finally, I 
am confident that if those physicians who are now in the habit of employ- 
ing the syringe for the removal of cerumen froin the external auditory canal, 
would cast aside their prejudices and give the instrumental method a fair 
trial, they would not be willing to submit themselves again to the sloppy 
thraldom of the syringe. The cases of impacted cerumen and of acute and 
chronic otorrhcea, taken together, constitute nearly fifty per cent, of all the 
cases that come under the observation of the aural surgeon. The mere 
mention of this fact is sufficient to convey a tolerably accurate idea of the 
amount of syringing which the advocates of this therapeutic method must 
do in every-day practice. 

As the cases of impacted cerumen differ from each other in important 
particulars, only very general directions can be given with regard to the 
proper mode of removing the impacted mass with instruments. In the first 
place, the physician must follow every step of the operation with the eye. 
He should use as large a speculum as the size of the canal will permit, and 
the illumination should be good. If the wax is quite soft, a small channel 
should be cleared, with the curette, for a short distance along the upper 
wall of the canal, in order to afford room for the introduction of the cotton- 
holder armed with a mop of cotton of suitable size. Two or three intro- 
ductions of the cotton-holder, armed each time with a fresh mop, will usually 
suffice to remove all the cerumen lying between the external orifice and the 
farther end of the channel made by means of the curette. The remainder of 
the mass is to be treated in precisely the same manner, until the whole of it 
shall have been removed from the auditory canal. If the wax is moderately 
firm in consistency, the entire mass may be removed piece by piece with 
the curette. The occasional use of the forceps will also be found advanta- 
geous, especially if the surgeon has succeeded, by means of the curette, in 
separating the mass, or a large portion of it, from its attachments to the 
walls of the canal. There are certain conditions in which the slender silver 
probe will be found a more useful instrument than the curette ; as, for 



DISEASES OF THE EAR. 63 

example, where a mass of cerumen is -wedged in between the drum-mem- 
brane and the anterior and lower wall of the canal. By giving to the end 
of the probe a slight curve, one can readily dislodge the mass and bring 
it within reach of the forceps. In those cases in which, after removing 
almost all of the obstructing mass, I have found the membrana tympani 
plastered over with soft cerumen, I have usually resorted to the syringe as 
the quickest and (to the patient) pleasantest means of removing this re- 
mainder of the accumulation. So long as the curette is made to pass flat- 
wise over the walls of the auditory canal, and so long as the force employed 
is applied in the direction from the peripheiy toward the centre of the 
canal, the patient will experience no pain and perhaps not even discomfort. 
If the canal is quite large and straight, the end of the curette may be bent 
in such a manner as to make the plane of the ring form an obtuse angle 
with the shank ; and the same kind of dissecting manipulation as that to 
which I have just referred, can then also be applied to the surface of the 
drum-membrane. As a rule, however, a sort of scraping motion is the 
only effective one that can be communicated to the ordinary curette when 
brought in contact with the membrana tympani. Under these conditions, 
therefore, the syringe may be used with decided advantage. 

If the physician, for any reason, decides not to use the instrumental 
method, he will find that in exceptional, though by no means rare cases, 
syringing alone will fail to dislodge the impacted mass. The only course 
left open to him, under these circumstances, is to employ some chemical 
reagent which possesses the power of softening masses of inspissated ce- 
rumen. Water alone, it is true, possesses this solvent power, but its action 
is extremely slow. Bicarbonate of soda, on the other hand, is quite rapid in 
its solvent action, and yet at the same time it may be used freely in con- 
centrated solutions, without fear of injuring the walls of the canal. A good 
way of obtaining a concentrated solution is to drop a pinch of the powder 
into the orifice of the auditory canal (the patient's head being turned well 
over toward the opposite side) and then to pour in, with a teaspoon, a few 
drops of warm water. At the end of from twenty minutes to half an hour, 
the impacted mass will be found to have become softened to a depth of one 
or two millimetres, or even more. The softened debris are to be removed, 
and the concentrated solution is to be applied a second and a third time, 
until the entire mass has become so softened or so loosely attached to the 
walls of the canal, that its removal by syringing is easily effected. 

Dr. Blake, of Boston, employs liquor potassse, or a solution of caustic 
potassa, for the purpose of softening hardened masses of cerumen. He 
arms the end of a probe or cotton-holder with a small mop of cotton, dips 
it into the solution, and then applies it accurately to the centre of the outer 
end of the mass. Under the influence of such a strong alkali, the ceru- 
men softens very rapidly, and so, little by little, he is able to bore a chan- 
nel through the centre of the plug. The remaining shell can then be easily 



64 DIAGNOSIS AND TREATMENT OF 

broken into a mass of loose fragments, which syringing will quickly bring 
away from the canal. 

Finally, one word more with regard to syringing in cases of impacted 
cerumen. One of the chief reasons why it so often fails to accomplish the 
desired result is this : the force of the current is spent upon the broad 
surface of the outer end of the plug, and tends therefore rather to drive it 
farther inward. The most effective plan is to direct the stream against one 
edge (preferably the upper edge) of the mass, in the hope of washing out a 
channel between the main body of the plug and the upper wall of the mea- 
tus. As soon as this has been accomplished, it will be found that the current 
begins to exert a vis a tergo upon a portion of the mass, and soon brings 
away fragments of considerable size. 

Complications. — The only complication of which it is my intention to 
speak in this place, is that of an acute inflammation of the canal. Cases of 
this kind are not very common, and it is a fortunate thing that they are 
not, for the pain which characterizes the disease is usually of a very severe 
type. In all the cases which have come under my personal observation the 
patient had postponed seeking medical aid until the pain had become al- 
most insupportable. By that time the orifice of the meatus had become 
closed by the swelling of the surrounding parts, and there was decided 
oedema of the skin covering the mastoid process. The tenderness involved 
both the temporal and the mastoid regions, though of course, it was most 
marked in the immediate vicinity of the canal. The pain was generally re- 
ferred to the entire side of the head, as well as to the parts more directly 
affected. Only the smallest size of speculum could be used at first, but 
gradually the ©edematous swelling yielded to the pressure made by the 
walls of the conical silver instrument, and eventually it was found practica- 
ble to employ one of the larger sizes. 

Where severe pain is found associated with the conditions described 
above, the question is very apt to suggest itself, Shall we wait for the sub- 
sidence of this inflammation of the cartilaginous portion of the canal, be- 
fore attempting to dislodge the impacted mass, or shall we proceed forth- 
with to remove it ? I have always held the view that it was better to re- 
move the plug as early as possible. Not even the most experienced sur- 
geon can say positively, under such circumstances, whether the middle ear 
is involved or not, and to what extent the deeper portions of the meatus, 
those held fast between the bony walls and the hardened plug of cerumen, 
are participating in the inflammation. In the absence of accurate knowl- 
edge with regard to these important points, I believe the safest course to 
pursue is to remove the impacted cerumen as soon as practicable, and thus 
place the patient under the most favorable conditions, both for maintaining 
his hearing and for obtaining relief from his acute sufferings. This course, 
furthermore, is perfectly justified by the results. In every instance that has 
come under my observation, decided or complete relief speedily followed 



DISEASES OF THE EAE. 65 

the removal of the mass. In one or two cases, the removal of only the outer 
half of the plug brought such marked relief that I thought it perfectly 
proper to postpone the removal of the rest of the mass until the following 
day. 

There is only one point to which I desire to call special attention in 
this connection. I refer to the employment of the conical specula as 
dilators. When well polished externally, they may be made to dilate a 
very narrow external orifice to one of really ample dimensions ; and that, 
too, without causing the patient more pain than he or she can readily bear. 
I have sometimes accomplished the same thing with the cotton-holder, 
armed with a firm, olive-shaped mass of cotton, smeared on the outside 
with vaseline or simple cerate. By gradually increasing the size of the 
mass of cotton, and pushing it slowly inward by a sort of boring motion, 
the canal may be dilated to the desired size in a remarkably short time. 

I have purposely avoided saying anything about desquamative inflam- 
mation of the auditory canal, as a complication of impacted cerumen, for 
the reason that I prefer to discuss the question under a separate heading, a 
few pages farther on. 



Acute Circumscribed Inelainimation. 
Furuncles. Boils. 

The external auditory canal seems to possess a special predisposition to 
furuncular inflammation. Infants and young children apparently escape 
the disease altogether ; or if boils do occur in such young subjects, they 
are so small and insignificant as not to attract attention. In children 
between the ages of five and fifteen, I have seen a few instances of the dis- 
ease, and should hardly be justified in speaking of it as rare at this period 
of life. In adults, however, it is a comparatively common affection, consti- 
tuting not less than two per cent, of all the forms of ear disease which 
come under the aurist's observation. 

Etiology and pathology. — Our knowledge of the causes which give rise to 
the formation of furuncles in the external auditory canal is very scanty. 
In a fair proportion of the cases which I have seen, the patients have pre- 
sented unmistakable evidences of not being up to the proper standard of 
health. In at least an equal number, however, the individuals have ap- 
peared to be perfectly healthy in all other respects than the one which led 
them to seek medical aid. In a few instances I have suspected a malarial 
origin for the local affection, but the grounds for this suspicion were in no^ 
case very strong. Among the exciting causes may be mentioned an irri- 
tating discharge from the middle ear or the deeper parts of the meatus. 
The entrance of salt water into the canal, seems, in a few cases, to supply 
5 



66 DIAGNOSIS AND TREATMENT OF 

an adequate exciting cause. Instillations of a solution of alum are also 
said to favor the development of furuncles in the auditory canal. Finally, 
it is a very common occurrence for furuncles to develop in the course of an 
eczema of the auditory canal. In these cases, however, it is not quite clear 
to what extent we should lay the blame upon the eczema, and to what 
extent upon the scratching and rubbing which the itching of the eczema 
provokes. 

In the development of furuncles in the external auditory canal, it is 
quite probable that in some instances a sebaceous follicle, in others a 
ceruminous gland, is the starting-point of the inflammation. "When the 
latter seems to be displaying its chief activity far beneath the surface, it is 
fair to assume that the starting-point of this inflammatory action can hardly 
have been a sebaceous follicle, the deepest portion of which lies but a short 
distance from the surface. It seems more reasonable to suppose that, in 
these cases of deep-seated inflammation, the final coil of a ceruminous 
gland has furnished the starting-point for the inflammation. In a third 
class of cases the pathology is quite different. Externally the appearances 
are the same as those observed in cases of genuine furuncles. The subse- 
quent course of the disease, however, shows unmistakably that a chondro- 
matosis, and not an inflamed sebaceous or ceruminous gland, is the real 
cause of the furuncular inflammation (vide Dr. Pomeroy's case, p. 46). 

Symptoms and course of the disease. — The patient first notices a little 
pain in the region of the ear, and, on pressing with his finger upon the 
parts, finds that they are slightly tender. Sometimes the pain is preceded 
by a decided sensation of itching in the canal. Little by little the pain 
increases in severity, the tenderness becomes more marked, and the ear 
feels full and heavy. Throbbing is sometimes a marked symptom. Deaf- 
ness is not observed until the swelling is sufficiently great to close the audi- 
tory canal entirely at the point involved. The pain, which at first is 
confined strictly to the ear, may afterward be referred to other parts of 
the head as well. It is often, for example, described as extending over the 
side of the head, or as shooting down into the lower jaw of the same side, 
or along the side of the neck. Not unfrequently the patients complain of 
their inability to eat solid food, on account of the pain which the motions 
of the jaw cause. If the furuncle is situated near the surface, it may rup- 
ture as early as on the second day ; the inflammation and pain subside then 
very quickly. If the seat of the inflammation is farther removed from the 
surface, spontaneous rupture may not take place before the seventh or 
eighth day, or even, in rare cases, not until after the lapse of ten days or 
two weeks. The average duration, however, of the painful stage, is, 
roughly estimated, from five to seven days. In some cases — probably the 
majority — the pain disappears quite suddenly upon the occurrence of a 
rupture of the abscess ; in others, little or no relief is experienced by the 
patient until some time afterward. In some instances, for a day or two 



DISEASES OF THE EAR. 07 

before the abscess ruptures, a scanty watery or slightly pinkish discharge 
is observed at the orifice of the canal. After the rupture, the discharge is 
usually purulent in character, and may even be quite copious. The dura- 
tion of the discharge varies greatly in different cases. Usually it ceases 
in the course of two or three days ; in a few cases, however, it may con- 
tinue for several days or even weeks. In these cases it will generally be 
found that a mass of granulation-tissue has formed at the point of rupture 
of the former abscess, and that the latter is perhaps still represented by a 
small cavity or ulcerated depression in the skin. In rare cases the abscess 
burrows down in the direction of the parotid gland. This course of the 
disease I have observed only twice. In the first case, the patient — a female 
fifty-three years of age, and of apparently strong constitution — consulted 
me ten weeks after the disease had first manifested itself. The right auri- 
cle, and especially the fossa conchee, was found to be red and swollen. 
The orifice of the auditory canal was closed by the swollen condition of the 
parts, and by the presence of a small mass of granulations springing from 
the base of the tragus. The deeper parts of the canal were not visible. 
There was considerable swelling in front of and below the auricle. On 
exploration with the probe it was ascertained that the mass of granulation- 
tissue at the orifice of the canal, concealed the entrance to quite a large 
cavity, situated chiefly below the tragus. Complete recovery followed in 
the course of about two weeks. In the second case, 1 the patient (a female, 
forty-three years of age) had been suffering from pain in the left ear for a 
period of nearly three weeks before I saw her. There had been no dis- 
charge from the ear. On examination, I found the orifice of the auditory 
canal closed by a circumscribed swelling, which presented all the appear- 
ances of a furuncle. A free incision through the mass failed, however, to 
reach pus. Three days later, I saw the patient a second time. The canal 
was even more swollen than before, and there was a noticeable swelling on 
the left side of the face, below and in front of the ear. Granulation-tissue 
had sprung up from the wound made by the incision. The pain had not 
abated. Four days later a copious discharge set in, and the patient ex- 
perienced decided relief from pain. When I saw her, three days later still, 
I found the swelling below the ear more pronounced than when I had last 
seen her. The cedematous swelling extended to quite a distance from the 
abscess. Pressure made upon the most prominent portion of the tumor, 
below the ear, caused pus to flow from an opening in the lower wall of the 
meatus. The patient then became an inmate of St. Luke's Hospital, and I 
lost sight of the case. 

In the first of these two cases it is quite possible that the disease orig- 
inated in a softening of the cartilage of the meatus, and not in an ob- 

1 Both of these cases have already been reported in the American Journal of Otol- 
ogy, Vol. II.. No. 1. 



68 DIAGNOSIS AND TKEATMENT OF 

structed and inflamed ceraminous or sebaceous gland. Or a simple furun- 
cular inflammation may have developed in a meatus whose cartilaginous 
framework was already the seat of a circumscribed area of softening ; the 
resulting pathological changes being more extensive and permanent than if 
the process had been strictly furuncular in character. The possibility of 
such a concurrence of different pathological processes was suggested to my 
mind recently upon seeing a case of acute circumscribed inflammation of 
the external auditory canal in an individual whose auricle (of the same side) 
was the seat of quite a deep, circular ulcer of only a few weeks' standing. 
In the absence of any other satisfactory explanation of the origin of this 
ulcer, I was strongly disposed to look upon it, as well as upon the more re- 
cent circumscribed inflammation in the cartilaginous portion of the audi- 
tory canal, as having originated in a genuine though limited chondromala- 
cosis. This case, unfortunately, passed from under my observation as soon 
as the pain had been relieved, and I am therefore unable to say whether any 
permanent deformity of the canal remained after the subsidence of the in- 
flammation or not. 

Some authors mention the occurrence of furuncles in the osseous por- 
tion of the auditory canal, and also speak of the extension of a furuncular 
inflammation from the cartilaginous to the osseous portion of the canal, and 
even to the membrana tympani and middle ear. I have occasionally seen 
abscesses develop in the cartilaginous portion of the auditory canal as a com- 
plication of a diffuse inflammation of the osseous portion of the same canal ; 
but I have never seen a case in which I could say, with any degree of confi- 
dence, that a genuine primary furuncular inflammation of the cartilaginous 
portion of the canal had extended to the osseous portion— i.e., had pro- 
duced in this part any changes that were at all worthy the name of inflam- 
mation. I have also never seen a case of primary furuncular inflammation 
in the osseous portion of the auditory canal. I have seen abscesses in this 
part of the ear, but their pathology is so intimately bound up with that of 
acute and chronic purulent inflammation of the middle ear that I prefer 
to speak of them under those headings. Furthermore, the term furuncle 
is scarcely appropriate for abscesses like these. 

Diagnosis. — In a simple uncomplicated case of acute circumscribed in- 
flammation of the external auditory canal, no difficulty whatever should be 
experienced in making a diagnosis. In the first place, the development of 
pain in the ear, without deafness and tinnitus, would naturally lead us 
to locate the inflammation outside of the middle ear. In the second place, 
the existence of more or less tenderness on pressure externally would 
strengthen this belief, especially if the pain had developed recently in an 
ear that had always before been healthy. Finally, an examination with the 
speculum and reflected light could hardly fail to remove the last doubt 
that might remain in our minds with regard to the nature of the affection. 

So much for the uncomplicated cases of primary acute circumscribed 



DISEASES OF THE EAE. 



69 



inflammation of the external auditory canal. The questions, however, which 
we are sometimes called upon to solve in complicated cases of acute circum- 
scribed inflammation of the auditory canal, may be far more difficult. Thus, 
for example, an inflammation of the middle ear may terminate in, or be as- 
sociated with, a periostitis of the bony portion of the canal. A circumscribed 
collection of pus may eventually form at the junction of the cartilaginous 
and osseous portions of the canal, or perhaps even in the cartilaginous por- 
tion. If the physician has the opportunity of seeing such a case in its ear- 
lier stages, and can watch its progress from day to day, he will experience 
no difficulty in interpreting the circumscribed swelling correctly. If such 
a case, however, is seen for the first time only after the swelling has at- 
tained such a size as to obstruct the view of the deeper parts of the canal, 
he may find it a difficult matter to determine correctly what has been the 
chain of events, and therefore what is the true significance of the tumor. 
In such cases a careful weighing of the history of the attack will greatly 
aid in confirming or correcting the impressions made upon the mind by 
ocular inspection. Again, a mastoid periostitis may lead to the develop- 
ment of an abscess in the posterior cutaneous wall of the auditory canal, 
not far from the external orifice. In some instances the employment of a 
curved probe, introduced into the artificial opening, or into that established 
by natural processes, reveals a limited area of denuded bone surface. In 
others, although the probe may not encounter exposed bone, the previous 
history of the case and the persistency with which the wound remains open, 
justify the diagnosis of a mastoid periostitis rather than that of a furuncle 
of the auditory canal. 

The i^rognosis of an acute circumscribed inflammation (furuncle) of the 
auditory meatus is in almost all respects good. We can unhesitatingly 
quiet the patient's fears with regard to the preservation of his hearing. So 
far also as my observation extends, life is never endangered by this form of 
aural disease. On the other hand, we cannot assure the patient that a 
second or even a third furuncle will not soon develop in the same ear. 

Treatment, — If it be admitted that neither the patient's life nor his hear- 
ing power is threatened by the disease, the chief indication will clearly be 
to relieve his suffering. It is a disputed point how this may best be ac- 
complished. Some of the best authorities unhesitatingly give the prefer- 
ence to incisions. Von Troeltsch says : "I am in the habit of incising fur- 
uncles at the earliest moment practicable, and do not even wait until it is 
reasonably certain that pus has formed. The earlier the knife is used the 
better." l Eoosa says : " The proper treatment is to make an incision at as 
early a period as possible, and then to continuously apply warm water, giv- 
ing the ear an uninterrupted warm bath, as it were. It makes no difference 
whether pus or blood be evacuated by the incision. The relief following is 



Lehrbuch der Ohrenheilkunde. Wiirzburg, 1868. S. 88. 



70 DIAGNOSIS AND TREATMENT OF 

generally immediate in either case." 1 Burnett says: "The knife is the 
quickest and surest way of escape from the pain of these furuncles in the au- 
ditory canal." 2 Hinton says : "In furuncles, as the rule, a free incision by a 
curved bistoury is always desirable." 3 Dalby says : " The whole meatus is 
so swollen that it is not possible to see the position of the abscess with a 
speculum. This point having been distinctly localized, the sooner an inci- 
sion is made into it the better, as by this the tension of the parts, to which 
the agonizing pain is due, is relieved." 4 Keene says : " The greatest ben- 
efit will, however, be afforded in severe cases by an early incision, which 
should be made as soon as the situation of the furuncle can be discovered 
by circumscribed redness, swelling, or tenderness." 5 With such a weight 
of authority in favor of the operation, the surgeon would certainly be justi- 
fied in drawing the conclusion that in acute circumscribed inflammation of 
the external auditory canal, a free and deep incision through the tissues 
most intensely inflamed is almost certain to afford speedy relief from pain, 
and check the further progress of the inflammation. Furthermore, the 
certainty of relief which characterizes deep incisions in cases of whitlow is 
also very apt to occur to his mind in this connection, and confirm him in 
his decision to trust to the knife. Although for several years past I have 
not been able to satisfy myself fully with regard to the value of incisions in 
the class of cases we are now considering, I have been conscious of an in- 
creasing lack of confidence in then* efficacy. As each new case presented 
itself, I have asked myself the question : Shall I incise the swollen meatus, or 
not ? Influenced by the fear that the inflammation might extend and do some 
permanent damage, I have nearly always decided the question in the affirm- 
ative. Quite recently, however, I looked through my records of cases for the 
purpose of ascertaining how far I was justified in attaching any value to this 
possibility of damage, and found that in not a single instance had an acute 
circumscribed inflammation of the external auditory canal led to really seri- 
ous results. The only question, then, that we should consider in this connec- 
tion is, whether or not incisions afford such certain and decided relief that 
we can confidently urge the patient to submit to the pain of the operation. 
My own experience justifies me in saying that the knife very often disappoints 
us in cases of acute circumscribed inflammation of the auditory canal ; the 
pain being relieved only for a short time, and the duration of the disease 
not being materially shortened. Some of the earlier writers on otology 
seem also to have held the same opinion with regard to the comparatively 
small value of incisions in this class of cases. Thus, for example, Erhardt 



1 A Practical Treatise on the Diseases of the Ear. New York, 1873. P. 130. 

2 The Ear: its Anatomy, Physiology, and Diseases. Philadelphia, 1877. P. 261. 

3 The Questions of Aural Surgery. London, 1874. P. 95. 

4 Lectures on Diseases and Injuries of the Ear. London, 1873. P. 26. 

5 The Causes and Treatment of Deafness. London, 1873. 



DISEASES OF THE EAK. 71 

says : " It is decidedly better to allow the abscess to open by natural pro- 
cesses than to accomplish this end by surgical interference." * Bonnafont 
says : "In private practice the use of the knife always frightens the pa- 
tient ; and unless the case is a very urgent one, and the patient himself is 
desirous to have the incision made, it is much better to allow the abscess 
to open of itself." J Finally, Wilde says : "As soon as we believe matter has 
formed and come some way to the surface, but not till then, we should 
make an incision." 3 

If we seek for the reasons why incisions are so uniformly successful in 
cases of whitlow, and so uncertain in their effects in acute circumscribed 
inflammation of the auditory canal, we shall find that the chief and perhaps 
the only reason lies in the fact that the anatomical relations of the two parts 
are wholly different. In the case of the finger, the incision is at once fol- 
lowed by a certain amount of gaping of the wound ; there is complete re- 
laxation of the parts. In the case of the auditory canal, a comparatively 
unyielding cylinder of cartilage surrounds the inflamed tissues and renders 
relaxation of the parts almost an impossibility. 

This question with regard to the employment of incisions in cases of 
acute circumscribed inflammation of the auditory canal cannot, it seems to 
me, be settled by laying down any well-defined rules. In a general way, 
however, I might state the case thus : 1. If the patient has been in suffer- 
ing for three or four days, and if local bloodletting or hot applications have 
failed to relieve the pain, we may with propriety urge upon him the advisa- 
bility of having the swollen canal lanced; and particularly so if the appearance 
of the inflamed part indicates that a collection of pus has already formed. 

2. If the patient has been in suffering only a short time (one or two days), 
and especially if the swelling is so general that we cannot locate accurately 
the spot where pus is probably forming, it is better not to make an incision. 

3. If doubt exists with regard to what course we should pursue, and if 
the patient shows a disinclination to be cut, his wish should decide the 
question of an operation in the negative. 

The best form of knife for incising furuncles in the meatus is a curved, 
sharp-pointed bistoury. If the swelling is well-defined, the incision should 
be made through the centre of it, the point of the knife being carried from 
within outward. The operation should be performed under illumination 
from the forehead-mirror, and the incision should be made of such a length 
and depth as will afford a free exit to the pus. If the swelling is not well 
defined, my plan is to introduce a cotton-holder, well protected with cotton, 
into the swollen canal, and then to exert pressure in different directions. The 
region of greatest tenderness is that into which I make the incision. It is 



1 Yortrage uber die Krankheiten des Ohres. Leipzig, 1875. S. 160. 
! Traite theorique et pratique des maladies de l'oreille. Paris, 1873. P. 18S. 
3 Practical Observations on Aural Surgery. Philadelphia. 1873. P. 192. 



72 DIAGNOSIS AND TREATMENT OF 

well to have at hand a large sponge and a basin filled with hot water. Im- 
mediately after the incision has been made, the hot and moist sponge should 
be held against the ear, for the purpose of quieting the pain, which for a 
few minutes is generally very acute. When the pain subsides, dry warmth 
may be substituted for the hot and moist application. The only objection 
to the prolonged use of moist heat under these circumstances is, that it 
favors the development of granulation-tissue in the wound. 

If it be thought best not to incise the inflamed meatus, we may trust 
to the employment of either moist or dry heat. Of the different methods 
of applying moist heat to the external auditory canal, I am disposed to give 
the preference to the hot douche, as by means of it we can bring the heat 
and moisture more directly in contact with the inflamed region than by 
any other method. Poultices are heavy and difficult to manage, but they 
certainly retain their heat a longer time than do any of the other substi- 
tutes. A pad, consisting of several thicknesses of soft flannel, and wrung 
out of hot water, makes a very light and agreeable substitute for a poultice. 
After it has been laid upon the ear, it should be covered over first with a 
piece of oiled silk, and then with a folded towel or another piece of dry 
flannel. A hop pillow, made of soft flannel and filled with dried hops, is 
preferred by some physicians to any other form of poultice, in painful 
affections of the ear. The pillow is to be steeped in hot water (or vinegar 
and water, as some prefer), and then wrung out with the hands until it is 
simply moist. Some patients dislike the odor of the hops, and, when this 
is found to be the case, the latter may be removed from the flannel bag and 
sponges substituted for them. All these different forms of poultices or 
moist applications require to be changed frequently, as they lose their heat 
rapidly. 

Circumstances may be such that hot water cannot readily be obtained, 
or the patient may dislike moist applications. In such cases dry heat will 
often be found efficacious in relieving the pain. A flannel bag, filled loosely 
with rock-salt or bran, and heated to the proper temperature, answers the 
desired purpose very well. Two such bags are better than one ; for while 
one is being used, the other may remain in the oven, ready for use as soon 
as the first one shall have lost its heat. In case of necessity, an ordinary 
kerosene lamp may be used to supply the requisite heat. With some rather 
stout wire a suitable frame can readily be extemporized, and upon this a 
tin pie-plate is to be placed, at a height of six or eight inches above the top 
of the lamp-chimney. After the bag of bran or salt has been placed upon 
the plate, a second plate may be laid upside down upon the first one, for 
the purpose of retaining as much of the heat as possible in this rude oven. 
Some patients who have tried both kinds of hot applications, the moist and 
the dry, express a decided preference for the latter. 

I have had no experience whatever with the local use of anodynes in 
cases of acute circumscribed inflammation of the auditory canal. They may 



DISEASES OF THE EAK. 



73 



possibly afford some relief, but I have never felt disposed to administer 
them in this manner. The introduction of glycerine, sweet-oil, or almond- 
oil commends itself still less to my judgment. Glycerine is by no means a 
bland and soothing fluid, and the oils may furnish a nidus for the subse- 
quent development of the penicilium glaucum, or some other variety of fun- 
gous growth, which the surgeon may find it very difficult to get rid of. 

Local bloodletting by means of leeches is very apt to disappoint us in 
cases of acute circumscribed inflammation of the auditory canal. In some 
instances it even aggravates the pain. I have never applied at one time 
more than seven leeches, and then only in full-blooded, vigorous individuals. 
If only three leeches are used, they may all be applied in front of the ear, 
viz., two in front of the tragus, and one in front of the incisura intertragica. 
If more than three are used, it is better to apply the additional ones behind 
the ear, close to the angle where the skin is reflected from the auricle upon 
the mastoid process, and at points below the level of the orifice of the ex- 
ternal auditory canal. If the patient's condition does not contraindicate it, 
I usually allow the after-bleeding to continue for at least half an hour. I 
then endeavor to arrest the bleeding by means of cotton-wool and direct 
pressure upon the bleeding-point ; or, if this fails after a fair trial, I resort 
to the use of styptic cotton. If the application of the leeches is left to a 
nurse or to some member of the patient's family, the precaution should be 
taken to mark with pen aud ink the spots where the leeches are to be ap- 
plied, as otherwise we shall be likely to find, at our next visit to the patient, 
that they have been applied at points so remote froin the canal that no bene- 
fit could reasonably be expected from the procedure. Glass leech-tubes 
will be found invaluable as a means of compelling the leeches to bite at 
certain fixed points. 

In addition to the local treatment, some general measures will almost 
always be found advantageous in this form of ear disease. Thus, for ex- 
ample, it is very often observed that these furuncles develop in persons who 
are run down in health, or who have been indulging in all sorts of dissipa- 
tion, or who have been subjected to prolonged mental anxiety. These er- 
rors should be corrected by the patient, and, in addition, it will be found 
advantageous to prescribe quinine or some preparation of bark. In some 
cases iron may also be prescribed to advantage. 

In a few cases, a small ulcerated cavity or excavation remains for some 
time after the abscess has broken and after all the acute symptoms have 
passed away. The only symptom that it produces is a slight discharge. In 
one or two instances I should probably have overlooked the small orifice of 
the cavity entirely, had I not searched for it with a bent probe, and had I 
not also known, from previous examinations, that in a particular part of the 
canal an abscess had recently broken. It is more common, however, to find 
a mass of granulation-tissue, of variable size, at the mouth of the cavity. 
In the former case, a single light cauterization of the cavity with a bead of 



74 DIAGNOSIS AND TREATMENT OF 

nitrate of silver, fused on the end of a bent probe, usually causes it to heal 
up completely. In the latter case, it is better first to remove the granula- 
tion-tissue growth with Blake's snare. In two or three instances I have 
found the stimulus of the nitrate of silver insufficient to produce the desired 
effect, and have then succeeded perfectly in causing the cavity to heal by 
employing pure nitric acid instead of nitrate of silver. I use for this pur- 
pose a slender silver probe with a platinum tip, and wind a little cotton- 
wool around the end before dipping it into the acid. The pain resulting 
from such an application is of very short duration. 



Acute and Chronic Diffuse Inflammation. 
(Otitis externa diffusa. Periostitis. Eczema. Otomycosis. ) 

It may seem strange to some that I should group these apparently dif- 
ferent conditions under one head. My reasons for doing so are simply 
these. While in certain cases I may be able to say, with some degree of 
positiveness : this is a case of acute periostitis of the osseous portion of the 
auditory canal ; or that is a case of chronic eczema of the meatus, — in the 
great majority I find it impossible to make a positive diagnosis. 1 Simple 
ocular inspection does not furnish all the evidence required, and we are 
obliged to fall back upon the patient's own statements with regard to the 
causes which produced the disease, the time when it began, the course 
which it pursued, etc. Such statements, however, are exceedingly untrust- 
worthy, and we are therefore often compelled to abstain from making an 
accurate diagnosis until sufficient time has elapsed to clear up some of the 
doubtful points. The most we can do under such circumstances is to rest 
satisfied with the diagnosis of an inflammation of the osseous portion of the 
auditory canal. So far as the patient's interests are concerned, — i.e., so far 
as the treatment is concerned, — it really makes very little difference whether 
we succeed, or not, in making a more accurate diagnosis than this. 

Etiology and pathology. — Primary diffuse inflammation of the osseous 
portion of the auditory canal is a disease peculiar to adult life. I do nut 
remember to have observed it in an individual younger than eighteen. 
This diffuse form of inflammation, unlike the circumscribed form in the car- 
tilaginous portion of the canal, can hardly be looked upon as an indication 
of overwork, of malarial poisoning, or of a poor general state of health. 



1 These remarks apply wholly to pathological processes involving chiefly the osseous 
portion of the external auditory canal. An eczema which does not extend inward be- 
yond the limits of the cartilaginous portion may very properly be considered as an ec- 
zema of a part of the auricle. At all events this is the disposition which it has seemed 
best to me to make of the subject. 



DISEASES OF THE EAR. 



iO 



On the contrary, I have observed it so frequently in men and women of 
stout habit, all of whom were at the same time rather high livers, that I 
am disposed to hold the view that excessive eating and drinking stand in a 
causal relation to this particular disease. I think Hinton must have had this 
very class of cases in mind when he wrote the following : "I also think that 
there is no form in which a gouty affection of the ear is so clearly marked 
as in a peculiar obstinate irritabihty of the meatus, attended with slight 
serous or sticky discharge, with itching and pricking pain, the walls being- 
somewhat swollen, with a tendency to purple in their redness. In these 
cases the membrane also is congested, but the structures of the tympanum 
may apparently scarcely be involved." 1 In the cases which have come un- 
der my observation I have not been able to establish the existence of a gouty 
diathesis. Bathing in salt water is often mentioned as an exciting cause. 
In rare instances the patient attributes the attack to exposure to cold while 
he was in a heated condition. 

In very many cases this form of disease is found associated with an ec- 
zema of the auricle or of the cartilaginous portion of the meatus, or the 
physical conditions observed in the osseous portion of the canal are pre- 
cisely the same as those observed in an eczema of the auricle. In these 
cases it certainly seems as if it would be proper to designate the disease 
as an eczema of the osseous portion of the external auditory canal. But 
these cases which are associated with an easily recognized eczema of some 
neighboring part of the skin, look precisely like those in which no such 
diagnostic clew exists. Owing to these difficulties in drawing a satisfactory 
distinction between the different cases, I decidedly prefer to apply to them 
all indifferently the term diffuse inflammation of the auditory canal. 

Symptomatology. — I am quite confident that I should fail if I were to at- 
tempt a description of the symptoms which characterize a diffuse inflamma- 
tion of the external auditory canal (osseous portion). This description 
might be quite truthful for some one particular case, but for all the others 
it would be inaccurate. The better plan, it seems to me, is to describe a 
few typical cases, and then to call attention to the salient points of these. 
I warn my readers, however, that these typical cases, although valuable be- 
cause they furnish proof that the disease in question may have an indepen- 
dent existence, are in reality quite exceptional. In actual practice they 
must expect to find the great majority of cases so complicated that the 
statement of the correct anatomical diagnosis would require a compara- 
tively long description. No short title, such as will be found at the begin- 
ning of this or other chapters of this treatise, would be likely to convey to 
the mind of any person who might read it, more than a very crude concep- 
tion of the pathological picture presented. It is often a very difficult task 
for the physician to acquire a clear conception of the actual sequence of 



The Questions of Aural Surgery. London, 1874. P. 93. 



76 DIAGNOSIS AND TREATMENT OF 

events in any given case of ear-disease ; and this is particularly true of the 
form which I am now endeavoring to describe. 

Now and then we have the opportunity of seeing a case of primary in- 
flammation of the skin lining the osseous portion of the external auditory 
canal, which is so free from complications that we can no longer doubt the 
existence of such an independent form of aural disease. The following 
case is one in point : The patient, a lady, twenty-two years of age, and in 
a fair general condition of health, stated that four days previously she had 
experienced quite a sharp pain in both ears. From that time forward she 
had suffered more or less with pain, but there had been no discharge and 
only a little deafness and tinnitus. On examination, it was found that the 
inner half of the canal, on both sides, was red, swollen, and covered with a 
pasty material consisting chiefly of epithelium. The membrana tympani 
on both sides was also red and swollen, but chiefly so on the right side. 
There was tenderness on pressure over both mastoid processes. There was 
no appreciable impairment of the hearing for ordinary conversation, and 
the watch, which at first could be heard at a distance of only one inch, was 
heard at a distance of at least six inches after the pasty epithelium and pus 
had been removed from the canal. There were no evidences whatever of 
an acute nasal or naso-pharyngeal catarrh, or of an external eczema, and 
the patient did not give any history of exposure to cold. The posterior 
half of the right membrana tympani was incised, but the middle ear was 
found to be quite free from secretion. Two leeches applied behind each 
ear, and the frequent use of the hot douche, speedily removed all the pain, 
and in the course of a few days the parts returned to their natural condi- 
tion. 

So far as the appearances presented to the eye are concerned, this case 
might perfectly well have been interpreted as one of primary acute inflam- 
mation of the middle ear, with secondary inflammation of the contiguous 
lining membrane of the osseous portion of the auditory canal. The cor- 
rectness of this diagnosis, however, is rendered improbable by the follow- 
ing considerations : An acute inflammation of the middle ear, of sufficient 
severity to seriously involve the osseous portion of the auditory canal in the 
short space of four days, would certainly have been associated with more 
decided impairment of the hearing, with a more highly swollen and vascu- 
lar condition of the tympanic mucous membrane, or with a free exudation 
into the cavity of the middle ear. In the absence of these conditions it 
seems perfectly proper to classify the case as one of a primary acute inflam- 
mation of the skin and periosteum of the osseous portion of the external 
auditory canal. The inflammation of the cutaneous surface of the mem- 
brana tympani is an almost inseparable accompaniment of such an otitis 
externa diffusa. In a few cases, however, I have found the drum-mem- 
brane so little involved that, after I had wiped away the secretion which 
covered it, and which came from the inflamed lining of the neighboring 



DISEASES OF THE EAE. 



77 



walls of the canal, it presented only very trifling evidences of inflammation. 
I have observed this non-participation of the membrana tympani more par- 
ticularly in those cases which were apparently eczematous in their nature. 

I may mention in this connection a second case of diffuse inflammation 
of the osseous portion of the meatus. The patient, a physician, thirty-two 
years of age, and in fair general health, stated that for a period of several 
months previous to the time at which I first saw him, he had been troubled 
with a serous or sero-purulent discharge from both ears, associated at times 
with pain. Occasionally the discharge ceased for several days or even 
weeks at a time. He had tried different plans of treatment, but they had 
all failed to give the desired relief. On examination, I found both auricles 
perfectly natural, and both external orifices free from any evidence of irri- 
tation. The hearing was not appreciably affected, either for the ticking of 
a watch or for conversation. The osseous portion of the auditory canal was 
found, on both sides, to be moderately swollen and congested, and covered 
with a pasty, whitish secretion. The peripheral and manubrial portions of 
both di-um-membranes were moderately congested. The only treatment 
attempted consisted in the application of a strong solution of nitrate of sil- 
ver (gr. 120 — 3 i.) to the inflamed walls of the canal, two or three times a 
week. A few such applications were made, but without producing any 
material benefit. Four months later I saw the patient again, and learned 
that he had had in succession, at short intervals, at least a dozen abscesses 
in both canals. He expressed himself as feeling very much discouraged 
about the condition of his ears. Everything else having failed, I suggested 
to him the idea of smearing the inflamed canal with Hebra's diachylon oint- 
ment, at regular intervals of time. Five months later still, he reported the 
speedy and entire success of the therapeutic measure suggested. 

In this case there was not the slightest evidence to show that the affec- 
tion was eczematous in its nature, and yet the remedy which finally accom- 
plished a rapid and permanent cure, was one that is almost considered a 
specific in eczema of other parts of the body. From this circumstance 
alone, however, we should certainly not be justified in drawing the infer- 
ence that the disease was eczematous in its nature. The following case 
also furnishes a good example of an otitis externa diffusa, with only slight 
implication of the dermoid layer of the membrana tympani. 

The patient, a lady, about twenty years of age, and in excellent general 
condition, consulted me in July, 1871, on account of a constant watery dis- 
charge from both ears. She said that during the previous month of March 
she had passed through an attack of scarlet fever, and that during conval- 
escence she had experienced pain in both ears, followed by a watery dis- 
charge which had continued ever since. There had been no pain, no deaf- 
ness, and no tinnitus. Once or twice the discharge had ceased entirely for 
a few days. On examination, I found the inner half of the meatus, on 
both sides, reduced in size by the swollen condition of its lining membrane. 



■m 



78 DIAGNOSIS AND TREATMENT OF 

The latter was also moderately red. The manubrial and peripheral por- 
tions of the membrana tympani were congested, and the intervening por- 
tions presented a soaked and opaque appearance. There was very little 
fluid in the canals — barely enough to moisten them. The ticking of a watch 
was heard at a distance of four feet, on both sides. The Eustachian tubes 
were freely pervious to air, and there was no noticeable catarrhal irritation 
of the naso-pharynx. Instillations of a solution of sulphate of zinc were 
prescribed. Four weeks later the patient returned to the city and reported 
that the discharge had rather increased than diminished under the treat- 
ment which I had advised. On examination, I found that no material 
change had taken place in the condition of the canals. I carefully wiped 
away all moisture from the inflamed surfaces and then filled the canal with 
a strong solution of nitrate of silver (120 grains to the ounce), the patient's 
head being turned well over toward the opposite side. As soon as she felt 
a distinct sensation of warmth in the ear, I removed the solution from the 
meatus by syringing it out with warm water. Both canals were treated in 
this manner. Two weeks later I saw the patient for the third time. No 
discharge whatever had been observed by her during the interval, and the 
ears then felt perfectly natural in every respect. 

On the 11th of September, 1878, — that is, seven years later, — she again 
came to see me with regard to her ears. According to her statement, there 
had been a discharge from both canals since the early part of the preceding- 
July. There had been no deafness, and the parts presented very nearly 
the same appearance as they did seven years previously. After drying the 
canals thoroughly, I applied powdered iodoform to the inflamed surfaces, 
and instructed the patient not to syringe the ears unless a discharge showed 
itself at the outer orifice. On the 14th I found the ears in precisely the 
same condition as on the 11th, and the patient had not observed any dimin- 
ution in the activity of the discharge. I again dried the canals, and applied 
powdered burned alum instead of iodoform. On September 20th, very little, 
if any, improvement having taken place in the meantime, I mopped out the 
inner half of each canal with a saturated solution of nitrate of silver ; the 
parts being kept thoroughly moistened with the solution until a distinct 
sensation of warmth was experienced by the patient. On the 25th of Sep- 
tember, I found the walls of the canals and the drum-membranes perfectly 
dry and free from noticeable redness. 

On the 25th of October she came again to see me, as her ears felt full 
and the discharge had returned. I again used the saturated solution of 
nitrate of silver, but allowed it to remain longer (about five minutes) in 
contact with the inflamed parts. Three days later she reported that she 
had experienced some pain after the last application of the silver solution, 
but that on the following day her ears had again felt quite natural, and the 
discharge had not returned since. From that time to the present (January, 
1880) I have not seen the patient, and believe that I am justified in assuming 



DISEASES OF THE EAK. 79 

that she has remained free from active irritation in her ears during this 
comparatively long interval. 

In a fourth case, which came under my observation quite recently, the 
eczematous nature of the affection was very plainly indicated. The patient, 
a girl, eighteen years of age, stated that for nearly a year she had had an 
intermittent discharge from both ears. On examination, I found both 
auricles noticeably red and covered with crusts. The canals were filled 
with pus and flakes of epidermis, in about equal proportion. The walls, 
however, showed very slight evidences of active irritation. The drum- 
membranes also showed merely a soaked and opaque appearance, but no 
marked swelling, such as we should have a right to expect if they had par- 
ticipated actively in the inflammation. The discharge seemed to come 
chiefly from the walls of the osseous portion of the meatus. The hearing, 
after the pus had been removed from the canals, was found to be quite 
good, both for the watch and for spoken words. The results of treatment 
may be briefly stated as follows : at the end of seven days, under the use 
of oil of Cade ( 3 i.) and vaseline ( 3 vij.), the auricles presented as natural 
an appearance as if the}' had never been covered with repulsive masses of 
crusts. At the end of four weeks, the discharge from the auditory canals 
was still as active as ever, and the patient's faith in an ultimate cure had so 
nearly vanished that she was unwilling to submit to further treatment. In- 
sufflations of powdered burned alum and of iodoform failed to exert the 
slightest influence upon the activity of the discharge. Twice the affected 
parts, the drum-membrane included, were painted thoroughly with acetum 
cantharidis, but it also seemed to exert no restraining influence upon the 
activity of the discharge, and — what was stranger still — did not even pro- 
duce the stinging sensation, or sensation of warmth, which it almost in- 
variably produces when applied to the auricle. On two or three occasions 
I succeeded in arresting the discharge entirely for several days at a time, 
by employing a strong solution (120 grains to the ounce) of nitrate of sil- 
ver. The last time, however, I employed a saturated solution, and allowed 
it to remain in the canal for several minutes. It failed, not only to arrest the 
discharge, but even to produce the customary sensation of warmth in the 
ear. As already stated, the patient at this stage became discouraged, and 
discontinued her visits. 

These cases illustrate sufficiently the symptomatology and course of the 
more typical cases of acute and chronic diffuse inflammation of the exter- 
nal auditory canal. The primary acute cases are comparatively rare ; on 
the other hand, acute exacerbations of the chronic form of the disease are 
often seen in aural practice, and are very apt to be associated with abscesses 
of the cartilaginous portion of the canal. This latter complication requires 
no further consideration in this place. There is another complication, 
however, which must be discussed at greater length. I refer to the growth 
of the different varieties of aspergillus in the inflamed canal. In this con- 



80 DIAGNOSIS AND TREATMENT OF 

nection I may say that I agree entirely with those authorities who consider 
the presence and growth of this vegetable parasite in the auditory canal or 
middle ear as simply an accidental complication, and not as an independ- 
ent cause of disease in either of these localities. The diffuse inflammation 
of the canal or the chronic inflammation of the middle ear, especially if a 
large perforation in the membrana tympani leaves this cavity unnaturally 
exposed to the air, supplies a soil suitable for the growth of the sporules or 
germs with which the air is everywhere and at all times filled. An ear in 
a state of active secretion of pus, or other fluid, is not likely to furnish more 
than a momentary lodgment to these germs. The character of the fluid 
secreted also probably has much to do with their development ; certain se- 
cretions being better suited for their growth than others. The cases in 
which the parasitic growth is most frequently observed are precisely these 
cases of diffuse inflammation of the osseous portion of the auditory canal. 
In the early stages of this disease the red and swollen skin lining the osse- 
ous portion of the meatus, and covering the outer surface of the membrana 
tympani, secretes just enough fluid to keep the parts moist, but not enough 
to give rise to a current. The conditions supplied here — moisture, absence 
of motion either in the fluid or in the surrounding air, and possibly dark- 
ness — are eminently favorable to the further development of the aspergillus 
germs. On two or three occasions I have had the good fortune to examine 
the ear just at the stage in which the fungus had reached its full aerial de- 
velopment. This happened in the following case : The patient, a female, 
thirty-five years of age, stated that about four weeks previously she noticed 
a sensation of fulness in the right ear, and, supposing that it was due to 
the presence of hardened wax, she dropped some sweet-oil into the meatus 
for the purpose of softening it. In the course of a few days she experi- 
enced a little pain in the affected ear, and again quite frequently during 
the following three weeks, but at no time was there any discharge. At the 
time I saw her, the hearing for the watch was reduced to T %. On exami- 
nation with the speculum and reflected light, the outer half of the meatus 
was found to be perfectly normal. The lower half of the drum-membrane 
and the lower wall of the osseous portion of the canal were covered with a 
continuous, white, fuzzy material, which looked very much like cotton-wool. 
Here and there the whitish surface was dotted with small black specks. 
The upper portion of the membrana tympani and the rest of the osseous 
canal presented a red and moderately swollen appearance. Portions of the 
material removed from the auditory canal were examined with the micro- 
scope and found to be composed of the whitish or yellowish white variety 
of the fungus, intermingled with occasional specimens of the black variety. 
Under the use of instillations of a weak solution of carbolic acid, the 
ear slowly improved, and when seen for the last time, about six weeks sub- 
sequently to her first visit, the parts had nearly returned to their normal 
condition. 



DISEASES OF THE EAE. 



81 



So far as my experience goes, it is quite common to find the black and 
white varieties growing side by side in the same ear. The white variety 
usually preponderates. Beside these two commoner varieties of fungus, 
there are others with which I have had no personal experience. Those who 
are interested in the subject will find these rarer varieties fully described 
in a paper recently published by Dr. Charles Burnett. 1 In former years I 
made a careful search with the microscope for the fungus in every sus- 
picious case. Perhaps once in five or six times I was successful in finding 
the parasite ; but, as the discovery never materially altered my plan of 
treatment, and as the searches consumed a great deal of time, I soon aban- 
doned the practice altogether. 

Diagnosis. — There is no difficulty whatever in recognizing the red, 
swollen, and perhaps moist condition of the osseous portion of the auditory 
canal. We can then say positively that a diffuse otitis externa exists. If 
the drum-membrane presents at the same time a normal or at least a non- 
inflamed condition, we can, with considerable confidence, make the diag- 
nosis of a primary inflammation of the osseous portion of the canal. The 
question of its acute or chronic nature can only be determined after we 
have heard the history of the case ; and even then we may readily be mis- 
led, as patients are often not aware of the existence of a chronic subacute 
otitis externa diffusa until their attention is called to it by the pain or sense 
of fulness caused by an acute exacerbation of the inflammation. The 
point, however, around which the greatest interest centres, relates to the 
condition of the middle ear in many of these cases. The drum-membrane 
being red and swollen, we naturally ask ourselves the question : Is the dif- 
fuse inflammation of the auditory canal merely an extension of that which 
is apparently going on in the middle ear ? or, Is the membrana tympani, 
by virtue of the intimate relations existing between its outer layer and the 
skin of the osseous portion of the canal, involved secondarily in an inflam- 
mation which really began in this latter region ? This question, as I have 
already stated, cannot be determined by inspection alone. We must test 
the healing, examine the condition of the naso-pharyngeal mucous mem- 
brane, and ascertain, by auscultation, during the act of inflation, the con- 
dition of the middle ear and Eustachian tube. If there is comparatively 
little disturbance of the hearing, if there is no evidence of an acute naso- 
pharyngeal catarrh, and if the air enters the tympanic cavity freely and 
without rales or crackling sounds, we are fairly justified in pronouncing the 
disease an acute primary diffuse inflammation of the external auditory canal. 

The presence of aspergillus can only be determined positively by 
placing some of the suspected products under the microscope, and demon- 
strating the presence of the stalks, and perhaps also of the fruit, of the 
parasitic plant. 



American Journal of Otology, VoL I. 
6 



No. 2. New York, 1879. 



82 diagnosis and treatment of 

Prognosis. — The different forms of diffuse inflammation of the auditory 
canal have very little tendency to damage the hearing, and apparently none 
whatever to spread toward the middle ear or mastoid cells. By direct ex- 
tension it may excite a subacute mastoid periostitis. It is very apt also 
to occasion, or be associated with, furuncles of the cartilaginous portion 
of the canal. In the acute cases the prospects for an early and complete 
cure are good ; in the chronic ones, our prognosis must be guarded, as the 
disease is at times exceedingly stubborn, and relapses are very common. 

Treatment. — Our treatment of this disease must vary according to the 
stage or condition in which the disease happens to be. Thus, for example, 
if pain is a prominent symptom, the warm douche will be found very effec- 
tive in allaying it. Other methods of applying dry or moist heat may an- 
swer the same purpose equally well. If the pain still continues, after these 
measures have been fairly tried, leeches may be employed with advantage. 
It is rare, however, that a primary diffuse inflammation of the canal gives 
rise to severe pain. If the parts have begun to secrete fluid, we should 
resort to the use of astringents. The rules which guide me in the choice 
of these local remedies are very simple. Now and then I yield to the 
temptation to try some new remedy in the hope of obtaining better results 
than those which I usually obtain. Whenever I do so, however, I almost 
invariably meet with ill-success, and am glad to return to the few remedies 
with which every physician is perfectly familiar, viz., sulphate of zinc, 
acetate of lead, and nitrate of silver. While the pain continues, I abstain 
entirely from the introduction of any other fluid but water into the canal. 
After the pain has subsided, and moisture begins to show itself in the 
meatus, I sometimes use sulphate of zinc, and sometimes acetate of lead. 
The latter remedy, on the whole, has proved more efficient in my hands 
than the former. With regard to the strength of the sulphate of zinc solu- 
tion, it is my practice to employ only quite weak solutions, viz., from two 
to five grains of the salt in one fluid ounce of water. In the case of the 
acetate of lead, I use either a two- or a three-grain solution, as follows : 

r> . Plumbi acetatis gi% ij. 

Acid, acetic, dil ttj, x. 

Aquae fl. f i. 

M. 

I instruct the patient to syringe out the ear as well as he can, and then 
to turn his head over toward the affected ear, in order to remove from the 
meatus any free water that might otherwise remain in it. After he has 
done this, he should hold his head in such a position that he can readily 
fill the auditory canal, by means of a dropper, with the solution which he 
proposes to use. It is not necessary to warm the solution beforehand, unless 
the bottle containing it has been standing in a very cold room or closet. I 



v. 

DISEASES OF THE EAE. 83 

have arbitrarily chosen five minutes as the proper length of time for the 
solution to remain in the ear, and instruct my patients accordingly. It is 
not necessary to syringe out the solution after it has remained for a suffi- 
cient length of time in the canal ; it is enough to allow it to run out of 
itself, the head being held in the proper position. The instillations should 
be repeated two or three times a day, as circumstances may permit. 

In the more chronic cases, and esj)ecially in those which are character- 
ized by a rather abundant secretion of fluid, it is almost useless to employ 
either sulphate of zinc or acetate of lead. I have repeatedly tried powdered 
burned alum and iodoform in cases of this kind, but rarely with any appre- 
ciable benefit. I might almost say that I have never obtained prompt and 
decided results in this class of cases except by the employment of the 
stronger solutions of nitrate of silver. This astringent seems to possess 
certain properties which apparently do not belong to any other astringent ; 
or else the properties which are common to them all are much more 
strongly marked in nitrate of silver than in any of the others. However 
this may be, it appears to me to be a well-established fact that no other 
drug possesses, in so high a degree as does nitrate of silver, the power of 
restraining, in inflamed tissues, the production of lymphoid corpuscles. In 
the disease which I am now considering, the best method of applying the 
remedy is by instillation. The physician should always make the applica- 
tions himself, as a person who is not in the habit of handling solutions of 
nitrate of silver will be quite sure to stain the patient's neck or clothing 
with the remedy. 1 Before we introduce the solution into the thoroughly 
cleansed meatus, the syringe and vessel of warm water should be placed 
within easy reach. After the solution (not previously warmed) has been 
dropped into the canal, my plan is, not to leave it there for any fixed period 
of time, but to allow it to remain until the patient experiences a distinct 
sense of warmth, or a throbbing sensation, in the ear. I always ask the 
patient beforehand to direct his attention to the ear, and to notify me as 
soon as he perceives either of the sensations referred to. With a solution 
of only sixty grains to the ounce, the sensation of warmth will generally 
not be felt by the patient until after the lapse of three or four minutes ; 
with a solution of double or treble that strength, the sensation is usually 
experienced much sooner. As soon as decided warmth, throbbing, or 
perhaps even a little pain, is felt by the patient, I proceed to syringe out 
the solution with tepid water. Very often a single such application of the 
nitrate of silver will be found sufficient to arrest the discharge completely. 
In other cases several applications will be found necessary. While I am 
not aware that there is any serious objection to the daily employment of 
these strong solutions, I have followed the practice of making such applica- 

1 While the stains are fresh, it is easy to remove them with potassic cyanide, or 
«ven, in some cases, with potassic iodide. 



84 DIAGNOSIS AND TREATMENT OF 

tions only on alternate days, assuming that it is better not to interfere with 
the inflamed parts too frequently. If the discharge is quite active, the 
patient should be instructed to syringe out or douche the ear with tepid 
water once or twice a day. 

If these measures fail, we may try the plan of smearing the canal with 
Hebra's diachylon ointment, or, better still, with the oil of Cade and vase- 
line mixture, or the patient may be put upon a course of internal treatment 
with Fowler's solution of arsenic. I have had too little experience, how- 
ever, with the latter plan of treatment, in cases of diffuse inflammation of 
the osseous portion of the canal, to express a decided opinion with regard 
to its efficacy. In a single case I have known beneficial effects to follow a 
prolonged radical change in the patient's diet and mode of life. To pre- 
scribe such a radical change, however, to a person who has been accus- 
tomed to rather high living, and who experiences comparatively trifling 
annoyance from his chronic diffuse otitis externa, would probably appear to 
him like suggesting the substitution of a greater for a lesser evil. 

Finally, it is necessary to consider the question how far we should mod- 
ify our treatment when we discover that a diffuse otitis externa is compli- 
cated by aspergillus. During the early part of my practice I attached 
great importance to the local use of such remedies as carbolic acid, abso- 
lute alcohol, etc., in the belief that the employment of some form of para- 
siticide was almost absolutely essential to a speedy cure. So far as the 
carbolic acid was concerned, I soon found that, even in very weak solutions 
(two grains or even one grain to the ounce), it frequently rather added to, 
than diminished, the existing inflammation ; and as for the alcohol, I could 
not satisfy myself that it possessed any special advantages as a local rem- 
edy in this disease. In one case I found that powdered iodoform seemed 
to act directly as a parasiticide. As this case presented other features of 
decided therapeutic interest, I may be permitted to narrate it briefly. 

The patient, a lady, thirty-five years of age, in excellent general condi- 
tion, though about six months advanced in pregnancy, stated that for a 
period of five or six weeks she had experienced uncomfortable sensations 
in the left ear, amounting at times to decided pain. During the previous 
twenty-four hours there had been a slight discharge from the auditory 
canal, and the pain had been more acute than usual On inquiring more 
particularly into her mode of life, etc., I learned that she had had so many 
miscarriages that her physician, as soon as the fact of the present pregnancy 
had been established, advised her to remain quietly in her room through- 
out the remainder of her term. At the time I saw her, November 30, 1875, 
she had been confined to her room at least three months, and had not — so 
far as I could judge from her well-nourished condition and rather ruddy 
face — materially changed her previous habits of eating. On examination, 
I found that a furuncle occupied the upper wall of the left meatus, close to 
the outer orifice. The inner half of the canal and the drum-membrane 



DISEASES OF THE EAK. 85 

were covered witli a whitish, pasty material, which I interpreted to be 
chiefly cast-off epidermis from the underlying inflamed skin. The mem- 
brana tympani was entire, and the ticking of the watch was heard readily 
at a distance of 2 feet. As the abscess had just broken, I advised no 
other treatment beyond the occasional use of the warm douche. 

On the 14th of December she reported that the pain had not returned, 
but that the ear felt full and heavy. She had also noticed that the water 
which had been used in douching her ear was full of whitish flakes. On 
examination I found the deeper portion of the canal stuffed full with a 
whitish material, interspersed with black spots, which, on microscopic ex- 
amination was found to consist partly of aspergillus (A. flavescens and A. 
nigricans) and partly of exfoliated epithelium. I prescribed instillations of 
a weak solution of carbolic acid (1J gr. to the ounce). 

On the 15th of December, for reasons which are not stated in my notes, 
I discontinued the use of the carbolic acid solution, and mopped out the 
inner half of the. canal with a saturated solution of nitrate of silver. 

On the 17th she stated that considerable pain followed the application 
which I made on the 15th, but that her ear felt much better at that 
moment than it had for some time past. On examination I found the 
membrana tympani and adjacent walls of the canal covered with a dirty- 
looking dry crust. With the view of softening and ultimately removing 
this scab-like formation, I advised her to resume the use of the douche, 
which had been discontinued during the previous two days. 

On the 19th I again found the canal almost filled with the parasitic 
growth. I removed it as thoroughly as possible, and then applied powdered 
iodoform very freely to the inflamed tissues. I also instructed the patient 
not to use the douche for several hours, in order that the remedy might be 
allowed sufficient time to exert its full curative effects. 

On the 21st I found the canal more tightly packed with the fungus 
than on any previous occasion. I cleaned and dried it thoroughly, and 
again applied the powdered iodoform freely to the inflamed surfaces. This 
time I instructed the patient not to use the douche unless a discharge 
should show itself at the outer orifice, or unless the pain in the ear should 
become quite severe. 

On the 23d the patient reported that she had experienced occasional 
twinges of pain in the affected ear, but had not discovered any evidences 
of a discharge. On examination I found the yellow powder still lying upon 
the drum-membrane and coating the inner end of the canal. The parts 
were still red and swollen, but they were perfectly dry, and not a trace of 
the fungus could be seen. As some of the hard, scab-like formations still 
remained in the canal, I ordered two or three instillations of a weak solu- 
tion of bicarbonate of soda, for the purpose of softening them. 

On the following morning she had quite a sharp attack of pain in the 
ear. Later in the day I made an examination, and found the meatus dry 



86 DIAGNOSIS AND TREATMENT OF 

and free from scabs, but decidedly more swollen. I accordingly recom- 
mended that two leeches should be applied in close proximity to the tra- 
gus. This was done, and on the following day I found her in a much better 
condition. The leeches had removed the last vestige of pain ; there had 
been no discharge ; she could hear the watch a distance of 2J- feet ; and, on 
examination with the speculum, I found that the redness and swelling had 
diminished in a very marked degree. Perfect recovery followed in the 
course of a few days. 

This case presents certain features which are of decided therapeutic 
interest. In the first place, the application of the saturated solution of 
nitrate of silver had arrested all secretion from the inflamed wall of the 
canal and dermoid surface of the membrana tympani. The meatus, there- 
fore, no longer provided a suitable soil for the growth of the aspergillus. 
If I had paid no attention to the scab-like formations in the canal, whose 
presence there could certainly have done no harm, and had abstained from 
introducing water into it, the patient would probably have made a rapid 
recovery from that day forward. The douching, however, probably relaxed 
again the recently secreting skin of the deeper parts of the canal, and so 
invited a new growth of the fungus ; in any event, it supplied again the 
moisture necessary to the development of its germs. The same mistake 
was also made after the first application of iodoform. Water was intro- 
duced into the canal only a few hours after the powder had been placed 
there, and the result was, the speedy development of the fungus a second 
time. The next time I used the iodoform, no water was introduced into 
the meatus for forty-eight hours, and inspection at that time showed a 
complete absence of the fungus. Water, however, was then introduced 
for the third time. A rather violent reaction followed, but, for some rea- 
son unknown to me, no visible growth of the fungus took place. 

I have so frequently, in this form of disease, had good reasons for be- 
lieving that the presence of free water, or even simply of moisture, in the 
auditory canal, has caused a return of the inflammation and discharge, that 
I now make a practice of carefully drying the meatus and the drum-mem- 
brane, and then of smearing them with vaseline and oil of Cade, before dis- 
missing the patient from my office. 

Desquamative Inflammation. 

This form of disease differs from the other forms of diffuse inflammation 
of the osseous portion of the auditory canal in that its products consist 
almost entirely of continuous sheets of epithelium. I was formerly ] dis- 
posed to consider the disease as quite distinct from that form of diffuse 



1 See an article on Desquamative Processes in the Ear, in the Medical Record of 
Dec. 15, 1877. 



DISEASES OF THE EAR. 87 

inflammation of the canal which we sometimes encounter in well-marked 
cases of eczema of the auricle. More recently, however, I have seen several 
instances of fully developed desquamative otitis externa in patients whose 
auricles or neighboring skin surfaces were affected with unmistakable ec- 
zema. I am therefore quite ready to admit that the disease may have some 
connection with eczema, or that all these different forms of diffuse inflam- 
mation of the auditory canal may be essentially one and the same disease. 
As a matter of convenience, however, it is advisable to keep these different 
varieties or types distinct in our minds, and to know them by separate 
names. 

A certain amount of desquamation almost always takes place in every 
case of acute diffuse inflammation of the auditory canal. No special impor- 
tance is attached to the phenomenon, and it passes for one of the regular 
manifestations of the disease. In those cases, however, to which the term 
" desquamative " should be restricted, the canal is often found tightly filled 
with layer upon layer of epithelium. We remove these products, and clean 
the canal thoroughly, but in a comparatively short time we find it again 
filled tightly with the same sort of laminated sheets of epithelium. Some 
of these cases have been under my observation now for nearly four years, 
but the desquamative tendency is apparently as strong to-day as it was four 
years ago. Furthermore, I have not observed the slightest disposition in 
any of these cases to change their peculiar desquamative type for one in 
which the secretion of pus is the predominant feature. It seems to me, 
therefore, that this form of diffuse inflammation of the auditory canal is 
better entitled to recognition as a separate disease than is any other form 
of diffuse inflammation of the canal. 

Etiology and symptomatology. — This disease, in its early stages, does not 
seem to be accompanied hj any symptoms that would be likely to call the 
patient's attention to the ears. At all events, I have never seen a case in 
which a perfectly healthy ear became the seat of changes, which I should 
be justified — in the light of the subsequent progress of the case — in consid- 
ering as the early manifestations of this disease, and I am therefore unable 
to describe the conditions which characterize these earlier stages. When 
the canal has become filled with the exfoliated epithelium, the resulting 
deafness or discomfort leads the patient to consult a physician, and it is in 
this advanced stage, therefore, that we first see this form of disease. Occa- 
sionally we see cases of diffuse inflammation of the canal which run an acute 
course, and which are characterized by the exfoliation of very large quan- 
tities of epithelium in sheets of perfect whiteness. In these cases, however, 
the canal returns to a normal condition after the subsidence of the acute 
symptoms, and we can therefore hardly consider the pathological picture 
presented as that of a commencing (chronic) desquamative inflammation of 
this region. How the disease begins, and what are its exciting causes, are 
questions which I am unable to answer. 



88 DIAGNOSIS AND TREATMENT OF 

The simpler forms of tlie disease are undoubtedly of common occur- 
rence, and will be found grouped, by many authors, among the cases of im- 
pacted cerumen. The appearances presented to the eye, before any efforts 
have been made to remove the obstructing mass, are very often those of 
impacted cerumen pure and simple. As we proceed to dissect out the 
mass, we find that beyond the outer layer (that nearest to the external ori- 
fice) of cerumen, lies a tough, leathery mass, composed of laminated epithe- 
lial sheets at the periphery, and of a conglomeration of dried pus, variously 
shaped masses of epithelium, crystals of cholesterin, cerumen, etc., in the 
centre. When we separate the outermost layer from the underlying skin, 
we find the latter in various stages of inflammation. In the milder cases, 
the skin will simply present a vivid red color ; in the severe ones I have 
found even well-marked ulceration. In many of these cases the drum- 
membrane seems to take no part in the desquamative process, which may 
be confined to the outer half or two-thirds of the osseous portion of the 
canal, and the inner third of the cartilaginous portion. In one of the cases, 
of which I kept a careful record, the region of vivid redness ended quite 
abruptly, at a distance of about five or six millimetres from the posterior 
and inferior margin of the drum-membrane. In another case I found the 
desquamative process limited to a boat-shaped depression in the lower wall 
of the osseous portion of the canal. No satisfactory history could be ob- 
tained in this case, but it seemed reasonably clear that at some time in the 
the past, probably in the man's boyhood, caries and exfoliation of quite a large 
portion of the lower bony wall of the canal had taken place. The chronic 
desquamative inflammation of the skin lining this excavation had caused the 
patient no pain or discomfort until the steadily increasing laminated mass of 
epithelium, no longer finding room for itself in the excavation, began to exert 
pressure. Then the patient experienced moderate pain in the ear and con- 
sulted a physician. The true condition of the parts was fully recognized, 
and prompt relief was afforded by dissecting the tough mass out from its 
bed in the bony canal. About once a year, during the past five years, this 
patient has experienced more or less discomfort in the ear, and has each 
time obtained entire relief by having the impacted mass removed. In a 
third case, 1 I saw the patient for the first time in 1875, and for the second 
in 1877. Both times I found the impacted masses to be composed of quite 
small flakes or fragments of epithelium intermingled with hardened pus. 
The face, neck, and hairy scalp bore unmistakable evidences of eczema. 
The walls of the canal, after the impacted mass had been removed, were 
found to be red and swollen, but comparatively smooth. The drum-mem- 
brane had apparently escaped altogether. As the impacted masses, on 
both the occasions mentioned, were found to consist of only small epi- 
thelial flakes, which did not show the slightest disposition to assume a 

1 Case III. in the article referred to at the beginning of this section. 



DISEASES OF THE EAR. 89 

laminated arrangement, and which furthermore were largely intermingled 
with dried pus, I was disposed to consider this case as distinctively eczema- 
tous in character, and quite different from those cases in which the desqua- 
mative process shows a disposition to produce chiefly laminae of epithelium 
intermingled with very little pus. Since the publication of the article re- 
ferred to, I have seen this patient twice, viz., in October, 1879, and again 
in January, 1880. Both times I found the laminated arrangement of the 
cast-off epithelium as well characterized as we ever see it. The last time 
I examined the ear I found that the inflammation of the canal had pro- 
duced actual ulceration of the cutaneous surface, especially along the lower 
wall and near to the drum-membrane. I was therefore in error when I 
supposed that a distinction could properly be made between these two 
classes of cases — the eczematous and the desquamative. 

I have already alluded to the fact that when the desquamative tendency 
becomes established, it seems to persist for a long time, and to retain its 
own peculiar type. The following case affords a good illustration of this 
fact, and also shows how the membrana tympani itself may participate in 
the desquamative process. 1 The patient, a strong, healthy sailor, consulted 
me at the New York Eye and Ear Infirmary, on the 23d of February, 1876. 
He complained of constant dizziness, and almost unbearable tinnitus in both 
ears " for some time past." No satisfactory information could be obtained 
from him with regard to the condition of Ins ears in previous years. The 
deafness was so marked that I was obliged to speak to him quite loudly in 
order to make myself heard. On examination both auditory canals were 
found to be filled with cerumen. After the removal of these masses, which 
were found to be composed entirely of cerumen, it was ascertained that a 
tough, leathery mass of laminated epithelium covered each membrana tym- 
pani to a depth of not less than one millimetre, and completely filled the 
recess at the lower and anterior portion of the inner end of the meatus. 
When touched with the probe the outer surface of the mass felt as hard 
and almost as smooth as parchment. The removal of these epithelial de- 
posits was accomplished by means of the slender probe, the forceps, and 
the curettes ; a solution of bicarbonate of soda having first been employed 
for the purpose of softening them and loosening their connections. The 
difficulty of the task was greatly increased by the circumstance that, when- 
ever the instrument touched the wall of the osseous portion of the canal, 
the patient was seized with an irresistible desire to cough. This " ear 
cough," interfered so seriously with my manipulations that it was not until 
the fifth or sixth sitting that I finally succeeded in removing the last layer 
of epithelium. The pain caused by the manipulations also increased the 
difficulty which the patient experienced, of keeping his head perfectly quiet. 
After the removal of these masses from both ears, the drum -membrane, on 

1 Case V. in the article published in the Medical Record. 



90 DIAGNOSIS AND TEEATMENT OF 

on each side, was found to be red, somewhat thickened, and adherent in 
its central portion to the opposite promontory. The neighboring walls of 
the canal also presented an inflamed appearance, but no recognizable ulcer- 
ation or inequalities of the surface. The dizziness and distressing tinnitus 
were in a great measure relieved by the removal of the obstructions, and 
there was a little improvement in the hearing. 

Since 1876 I have seen the patient twice, and both times I have found 
the same pathological appearances as those already described. 

In a fifth case, finally, the desquamative process was allowed to go on 
unchecked for a long time — probably for a period of twenty years, until the 
bony canal which contained the laminated epithelial mass, became dilated 
to fully twice its normal size. After the impacted mass had been removed 
with considerable difficulty, the walls of the dilated portion were found to 
be in an ulcerated and granulating condition, with a limited area of ex- 
posed bone surface. The inner wall of this large cavity presented the ap- 
pearance of a uniform granulating surface, in which not a trace of the mem- 
brana tympani, ossicles, or labyrinthine fenestra could be distinguished. 
While a great deal of this damage might legitimately be looked upon as the 
effect of prolonged pressure exerted by a mass located in the auditory canal, 
it seemed to me more than probable that the original disease, out of which 
this desquamative affection subsequently grew, was a destructive inflamma- 
tion of the middle ear. However, the patient, a woman of average intelli- 
gence and forty-one years old, was positive that she had never had a dis- 
charge from the affected ear, but admitted that, for a period of twenty years, 
she had experienced frequent earaches and more or less deafness in that 
ear. 

Diagnosis and prognosis. — The products of this form of inflammation are 
so easily distinguished from pus and cerumen that an error in diagnosis 
can hardly occur. It is only in cases like that of the sailor (see preceding 
page) that some difficulty might be experienced in recognizing the true con- 
dition of things in the ear. The dry, hard, and comparatively smooth cul- 
de-sac at the inner end of the auditory canal would be very likely, at first 
sight, to be taken for a greatly thickened drum-membrane. In the case re- 
ferred to, the correct interpretation of the condition observed suggested it- 
self at once as soon as the curette had been used. At almost all points the 
hardened mass that occupied the inner end of the meatus passed, without 
any noticeable line of demarcation, into the neighboring skin of the canal. 
In one or two places, however, a free edge of thin cuticle indicated where 
the line of separation occurred. The curette was applied to these points, 
and, with a little cautious dissecting, the fact was ascertained that the thin, 
free edge of cuticle constantly grew thicker as the dissection was continued 
farther and farther inward. The desquamative nature of the affection was 
thus established beyond a reasonable doubt. 

With regard to the prognosis of the disease, I should not be justified in 



DISEASES OF THE EAE. 91 

expressing any very positive opinion. The simple removal of the obstruct- 
ing mass almost always affords the patient such marked relief that he does 
not care to submit to a course of treatment which has for its object, not the 
relief of a present trouble, but the prevention of a future one. My experi- 
ence in the radical treatment of the disease is therefore very small, and I 
must limit myself to the statement that, if left to itself, the disease is quite 
certain to reproduce the impacted state in from two months to two or three 
years. 

Treatment. — If the auditory canal is filled with laminated epithelium, 
dried pus, and other matters, the first step in the treatment should be to 
remove the impacted mass. The quickest way of accomplishing this is to 
dissect out the mass, or loosen its attachments with the curette, and then 
to extract it with the forceps, or with the curette used as a pry or shallow 
hook. If the mass does not form a connected whole, it must be broken 
down into fragments and removed piecemeal. The syringe alone, in this 
class of cases, will be found a very inefficient instrument. I have repeatedly 
seen cases where, after the syringe had been used several times in succes- 
sion without success, the mass was easily removed in a few minutes by 
means of the curette and forceps. If the desquamated epithelium is found 
firmly adhering to the membrana tympani, in the form of a continuous 
leathery mass, it is advisable to soften it first before we make the attempt 
to detach it from the membrane. Strong solutions of bicarbonate of soda 
may be used for this purpose. 

Once the impacted mass has been removed, the question confronts us, 
How can we prevent the canal from again becoming obstructed with a 
similar accumulation ? or, in other words, How can we radically cure the 
desquamative inflammation of the auditoiy canal ? So far as my own expe- 
rience goes, I am unable to give any satisfactory answer to this question. 
I have obtained the best results from the daily use of the lukewarm douche, 
continued for a period of several weeks ; but I cannot report a single in- 
stance in which, by this means, or by instillations of weak solutions of the 
acetate of lead, a well-marked chronic desquamative otitis externa, with in- 
tact drum-membrane, was really cured. It would be manifestly unfair, 
however, to pronounce the disease incurable upon the very limited experi- 
ence which I have had, and yet it is hard to see how anything like an ex- 
tended experience in the radical treatment of the disease is to be gained. 
In private practice persons whose ears feel perfectly natural, and whose 
hearing is fairly good, are usually not disposed to undergo a long course of 
treatment directed solely to the ear. In infirmary practice, it is useless to 
even suggest such a course of treatment. 



92 DIAGNOSIS AND TREATMENT OF 



Ulcees, Polypoid Geowths, and Caeies. 

The pathological conditions enumerated in the above title are sometimes 
encountered as independent affections. By this I mean, first, that ulcers 
and polypoid growths — and possibly also caries — may occur as genuine 
primary affections of the auditory canal ; and second, that all three condi- 
tions, although at first simply accompaniments or sequelae of a purulent in- 
flammation of the middle ear, or of some other local disease, may be raised 
to the dignity of primary or independent diseases through the complete sub- 
sidence of the original affection. Thus, for example, no one will dispute the 
primary J or independent nature of syphilitic ulcers and condylomata of the 
auditory canal ; and with regard to the occurrence of similar non-syphilitic 
lesions in this part of the ear, my impression is that they always represent 
the effects of some antecedent more general disease of either the meatus 
itself or of the middle ear ; and as they form an essential part of those dis- 
eases, it will be more appropriate, I think, to describe them under those 
headings than in the present section. So far as the independent occurrence 
of the lesions under consideration is concerned, my entire experience is set 
forth in the following histories of cases. 

The first case is that of a healthy boy, seventeen years of age. On the 
7th of April, 1877, he consulted me for the first time, and gave the follow- 
ing history of his trouble. During the previous summer he had passed 
through an attack of typhoid fever, and while he was convalescing a large 
abscess developed in the right parotid region. 2 This abscess broke and dis- 
charged its contents through an opening in the right auditory canal. From 
that time to the present there had been more or less discharge from the 
ear, but on the whole it had been diminishing in quantity. He had experi- 
enced no deafness with it, except temporarily, when the discharge filled the 
canal. About three months previously he had discovered a small fragment of 
bone in the discharge. On examination, I found a flattened, succulent mass 
of granulation tissue lying on the lower and posterior wall of the canal, ap- 
parently at the junction of the osseous with the cartilaginous portion. This 
mass, as I ascertained by careful probing, grew from the edge of a not very 
deep ulcer, at the bottom of which denuded bone was readily felt. A short 
distance beyond, in the osseous or membranous part of the canal, a second 
superficial ulcer was found. At all other points the canal presented an un- 
infiamed and natural appearance. The membrana tympani also appeared 
to be normal. 

Treatment was commenced on the 19th of April, and on the 29th, ten 
days later, the larger ulcer was found to be completely healed. The poly- 



1 That is, not developed by extension from a neighboring region. 

2 Parotid abscesses are said to be among the very rare sequela? of typhoid fever. 



DISEASES OF THE EAR. 93- 

poid mass was first removed with the snare, and then the remaining raw 
surfaces were freely cauterized (daily) with nitrate of silver, fused upon the 
end of a cotton-holder. Five or six such cauterizations were made, and then 
the rapidly contracting ulcer was completely covered with pellets of pow- 
dered burned alum. After two or three such applications, complete cicatri- 
zation of the parts was found to have taken place. The more deeply situ- 
ated, superficial ulcer, which seemed a very trifling affair in comparison with 
that which lay nearer to the external orifice, proved the more rebellious 
of the two. In fact, it had not yet entirely healed on the 29th, when the 
boy returned to his home in the country. A few weeks later, however, he 
visited me again, and I then found that this ulcer too had completely healed ; 
no further treatment having been carried on in the meantime. 

If this case could have been seen from the very beginning, it would 
probably have been an easy matter to trace the connection between the 
parotid abscess and the superficial ulcer which was situated near the drum- 
membrane. In all probability the abscess did not break until it had kin- 
dled an acute inflammation of the entire lower and posterior wall of the 
osseous meatus. The outer ulcer probably represented the spot where the 
rupture finally took place, and the inner one a spot where the inflammation 
was more severe than at other points. At the time I saw the case, however, 
the isolated position of this ulcer, and the absence of any evidence of in- 
flammation of the parts lying between it and the outer ulcer, added a cer- 
tain element of mystery to the case. 

In the second case, which was first seen on the 20th of November, 1877, 
the conditions observed were even more difficult to explain. The patient, 
a very intelligent lady, thirty-eight years old, and in fairly good health, 
stated that during the previous five weeks she had experienced at times quite 
severe pain in the right ear. There had been no discharge, and very little 
disturbance of hearing, so far as general conversation was concerned. Her 
regular medical adviser had attributed the painful affection of the ear to 
impacted cerumen, and had syringed the canal very thoroughly with tepid 
water, but without beneficial effects. On examination, I found the orifice 
of the right auditory canal tender on pressure, and obstructed by the pres- 
ence of a moderately large mass of granulation-tissue springing from the 
mouth of a recently ruptured furuncle. Beyond this fleshy mass, which I 
at once removed with the snare, the canal was found to be tightly plugged 
with a whitish mass which felt as hard as chalk. By means of the curette 
and forceps I was able to break down and remove piecemeal the entire 
mass. It presented throughout every appearance of being a chalky sub- 
stance, and probably represented a calcareous transformation of pus that 
had first undergone cheesy degeneration. The inner end of the mass ex- 
tended to within a few millimetres of the drum-membrane. After it had 
been entirely removed I found that the only lesion in the osseous part of 
the canal, beyond a moderate degree of redness and swelling, was a cir- 



9-i DIAGNOSIS AND TREATMENT OF 

cumscribed ulcer, situated posteriorly and superiorly, not far from the junc- 
tion of the osseous with the cartilaginous portion. On exploration with 
the probe, I ascertained that denuded bone surface constituted the base of 
the ulcer. The membrana tympani appeared to be perfectly normal. 

An examination of the patient's left ear, which she had always supposed 
to be healthy in every respect, revealed the existence of a small, pale, succu- 
lent, polypoid mass, springing from the posterior wall of the osseous canal, 
close to the drum-membrane. The secretion from this mass was so scanty 
that no fluid could be seen in the canal except in the immediate neighbor- 
hood of the growth. Exploration with the probe showed that the polypus 
was simply a superficial outgrowth, not connected with any demonstrable 
disease of the bone. The membrana tympani appeared to be perfectly nat- 
ural, and there was no appreciable redness or swelling of the walls of the 
canal in the vicinity of the growth. 

I questioned the patient carefully with regard to the condition of her 
ears in the past, but could elicit no information that threw any light upon 
the peculiar lesions found. The pain of which she had complained during 
the previous five weeks was evidently due to the development of a furuncle 
near the outer orifice, and the mass of granulation tissue found in this loca- 
tion was simply the effect of continued irritation from some source or other. 
These lesions were clearly of comparatively recent date. The presence of 
the calcareous mass in the right meatus pointed clearly to a discharge of 
much earlier date ; but it was not so easy a matter to define the location 
from which this discharge came. The middle ear, for instance, could safely 
be excluded as a source of the pus, as the patient was positive that she had 
never experienced any pain or discomfort in the right ear until recently, 
and also because the condition of the drum-membrane, as found after the 
chalky mass had been removed, showed no trace of any recent or former 
inflammation of the middle ear. The discharge, therefore, in all probability, 
came from the auditory canal. The patient, however, it will be remem- 
bered, stated distinctly that she had never observed a discharge from 
either ear. In explanation of this apparently contradictory state of things, 
the assumption seems almost unavoidable that in the outer portion of the 
canal there must have been some obstacle which prevented the escape of 
the pus secreted in the inner portion. Impacted cerumen would present 
such an obstacle, and, by greatly diminishing the rate of evaporation, 
which would take place in the pus, under ordinary circumstances (i.e., in 
an unobstructed meatus), would favor its gradual accumulation and slow 
transformation first into a cheesy and then into a chalky mass. No ceru- 
men, it is true, was found in the canal at the time I examined it ; but it is 
more than probable that the thorough syringing, which the ear had received 
at the hands of the attending physician, had removed all that was there. 

The question relating to the exact source of this assumed discharge, 
whether the latter came from the circumscribed ulcer described above, or 



DISEASES OF THE EAE. 95 

from some previous diffuse inflammation, of which this ulcer was the last 
remaining trace, is one which I am unable to answer. With regard to the 
treatment and subsequent progress of the case, there is very little of inter- 
est to communicate. Both ulcers healed slowly under the use of nitrate of 
silver (in the form of a bead) and (later) powdered iodoform. A dry eczema, 
affecting the orifices of the canals, continued for several weeks after the 
ulcers had healed, and then itself finally disappeared. As late as during 
the summer of 1879 I found both canals still quite natural in appearance. 

Li the foregoing cases the bony structure of the meatus was involved to 
only a very slight degree, and after the ulcer had healed, no irregularity 
of the surface remained to indicate the spot which it had recently occupied. 
In the following cases the disease of the bone constitutes a more prominent 
characteristic. In common with the case last described, however, they both 
were seen for the first time only after they had reached a more or less ad- 
vanced stage of development. Neither the condition of the parts nor the 
patient's own statements furnished the slightest clew to the antecedent 
pathology of the disease. 

The first of these cases was seen at the N. Y. Eye and Ear Infirmary on 
the 25th of October, 1871. The patient, a healthy man, twenty-two years 
of age, sought relief at the institution on account of an acute affection of 
the left ear. As a matter of routine, I also examined the right ear, of 
which the patient had made no complaint, and found the canal blocked by 
a large and hard plug of cerumen. After the mass had been extracted, I 
discovered that a ridge of bone, about two milhmetres high, crossed the 
lower wall of the osseous canal, at right angles to its long axis, and only a 
short distance from the line of junction of the cartilaginous and osseous 
portions. Along its sides this ridge was covered with small, soft granula- 
tions. Quite firm pressure with the probe failed to break off any portion 
of the irregular, free edge of the ridge. The drum-membrane showed only 
insignificant changes, and there was simply moderate redness of the canal 
in the neighborhood of the carious region. The watch was heard at a dis- 
tance of 6 feet. No evidences of syphilis could be found, and the patient 
was very positive that he had never had a discharge from the right ear, and 
had never experienced pain in it. (The patient was seen again only once, 
a few days later.) 

The second case was seen on the 17th of March, 1873. The patient, a 
strong, healthy man, of fifty years of age, consulted me for a slight diminu- 
tion in the acuteness of his hearing. On examination, I found both canals 
filled with cerumen. The impacted masses were removed, and the patient 
obtained the desired relief. 

On the 23d of June he consulted me a second time, and on examina- 
tion I was surprised to find that the canals were again obstructed with the 
same material, though in smaller quantity. The removal of the impacted 
masses again afforded the desired relief. 



96 DIAGNOSIS AND TREATMENT OF 

On the 26th of July the patient consulted me for the third time. The 
right ear, he said, had felt full, and at times he had experienced pain in it. 
On examination, very little cerumen was found in the outer portion of the 
canal, but in the immediate vicinity of the membrana tympani, there was a 
small mass of what appeared to be cerumen. As this mass was firmly im- 
pacted in the anterior cul-de-sac, between the drum-membrane and the 
wall of the canal, I instructed the patient to use instillations of a warm so- 
lution of bicarbonate of soda for two or three days, and then to let me ex- 
amine the ear again. This he did, and when I afterward saw him, I found 
no difficulty in syringing out the accumulated material. An inspection of 
the canal then revealed the fact that an irregularly shaped body still occu- 
pied the extreme inner end of the meatus ; part of it, in fact, seemed to be 
touching the membrana tympani. The free surface of this mass was made 
up of three or four jagged elevations, which felt like bone when they were 
touched with the probe. One of them was so prominent that I found no 
difficulty in seizing it firmly with the forceps. It was perfectly immovable, 
however, and there could therefore no longer be any reasonable doubt that 
this jagged ridge was in reality an exostosis or hyperostosis associated with 
a limited ulcerative process or caries ; the material which I had last syringed 
out being in all probability hardened pus which had accumulated around 
the bony mass. The membrana tympani was moderately thickened and 
opaque, but free from all other evidences of old or recent inflammation. 
The ticking of the watch was heard at a distance of 2 feet on the right 
side, and 4 feet on the left. Careful inquiry into the patient's past history 
failed to throw any light upon the origin of this local caries of the meatus. 
The left ear was not examined. 

On the 4th of September, 1874, the patient consulted me again. He 
said that he had experienced no unpleasant sensations in either ear until 
quite recently, when a slight discharge developed in both ears. On exam- 
ination I found that the carious spot in the right meatus was covered with 
foul and cheesy pus, and that almost the same lesion existed in the left 
canal. In both ears the carious spot was situated on the lower wall of the 
meatus, close to the drum-membrane, and on both sides the spots were of 
about the same size. 

On the 14th of November, 1876, the patient reported that during the 
previous summer he had experienced two or three attacks of moderately 
severe pain in the left ear, accompanied by a discharge of foul matter. 
At about the same time he had found two small fragments of bone in the 
discharge. The right ear had given him no trouble, though on one or 
two occasions he had noticed a slight discharge from it. On examination 
I found that the carious excavation in the left ear had increased decidedly 
in extent, and that a ridge of newly formed bone, about two millimetres in 
height, traversed the canal along the inner limit of the ulcer, and in close 
proximity to the membrana tympani. A very foul, dark pus covered the 



DISEASES OF THE EAK. 97 

region of the ulcer. On the right side no material change could be made 
out in the condition of the ear. 

The subsequent treatment consisted simply in the regular use of the 
warm douche, for the purpose of removing the foul pus from the canal ; the 
patient being unwilling to submit to any more systematic efforts to induce 
permanent healing of the carious spots, especially as I could not promise to 
him successful results. 

The thought of syphilis suggested itself to my mind, as soon as I dis- 
covered that both osseous canals were symmetrically diseased ; but the pa- 
tient's ruddy countenance and splendid physique, his age, his high social 
standing, and the absence of any other evidence of constitutional syphilis, 
made me look upon this disease as a very improbable cause of the peculiar 
lesions described above. The only hypothesis which I can offer in place 
of the syphilitic one, is that which represents these lesions as being the se- 
quelae of a double otitis media that ran its course during the patient's in- 
fancy or childhood, but of which all traces had long before disappeared. 

In the following case, which deserves the title of primary caries of the 
osseous portion of the external auditory canal more fully than does any case 
that I have ever seen, the exact pathology or mode of development of the 
disease is by no means clear. The patient, a healthy woman about thirty- 
five years of age, a member of one of the sisterhoods of the Episcopal 
Church in this city, consulted me on the 9th of Juue, 1880, for the purpose 
of having a " tumor " removed from the left ear. The only history that she 
could give was this : About three weeks previously she experienced a slight 
pain in the left ear, and a few hours later she noticed that there was a 
slight discharge from the ear. She paid very little attention to the dis- 
charge, as it was very slight and gave her no special annoyance. Two or 
three days before she came to see me, she noticed that her hearing had 
rather suddenly become impaired, and on examining the ear to ascertain 
what might be the cause ot it, she discovered that the outer orifice was 
nearly closed by a red, fleshy mass. Thinking that she might have made 
light of the degree of pain experienced at the beginning of the disease, I 
questioned her very closely on this point. She was very positive, however, 
that she had experienced only a few twinges of pain at intervals during a 
part of one day, and these twinges, she said, were almost too trivial to de- 
serve the name of pain. The hearing, so far as she knew, had always been 
perfect up to the time referred to above. On examination, I found the 
outer orifice blocked by a red, moist, firm, fleshy mass which sprang by a 
broad base from the lower and posterior wall of the meatus, a very short 
distance outside the line of junction of the cartilaginous with the osseous 
portion of the canal. From the firmness of the mass, from its uneven sur- 
face, from the painless manner in which it had developed, and from its ra- 
pidity of growth, I was at first disposed to consider it as a cancerous 
growth ; but after I had cut it off flush with the level of the surrounding 



98 DIAGNOSIS AND TKEATMEOT OF 

healthy skin, — a procedure which caused her very little pain, — I observed 
that a canal ran through the centre of the tumor, from its base to its sum- 
mit, and I at once abandoned the idea of a cancer. These hollow tumors, 
in my experience, grow only from the mouth of an abscess, be the latter 
simply furuncular in its nature, or of deeper origin (dependent on bone- 
caries). In the present case, the introduction of a curved probe revealed 
the existence of a limited area of exposed bone, which felt like the free 
outer edge of the osseous meatus. The drum-membrane and the inner 
half of the external auditory canal seemed to be normal, and the removal 
of the growth restored the hearing perfectly. 

On the 20th of June, after fruitless efforts to arrest the growth by means 
of nitric acid, I again resorted to the use of the knife. I took this step be- 
cause the fleshy mass had again nearly filled the orifice of the auditory 
canal, and therefore threatened to diminish the patient's hearing power 
during her vacation, which she was then about to take. 

On the 16th of July she returned to the city, and reported that during 
the first two or three days of the month her ear became very much swollen, 
below and behind the meatus ; and while it was in this condition she dis- 
covered, at the orifice of the canal, in wiping it out, a small fragment of 
bone. The swelling then rapidly subsided, the discharge ceased, and the 
ear seemed to her to return to a perfectly natural condition. The only 
trace of the former disease that I could find, when I examined the ear, was 
a small nodular cicatrix, at. the spot where the granulation-tissue had previ- 
ously existed. 

It would be extremely interesting to know what were the precise 
changes that led to the limited death of the bone in this case, but unfor- 
tunately we can only speculate with regard to their nature. The almost 
entire absence of pain during the incipient stage of the disease, coupled 
with the fact that a separation was found to have taken place between the 
projecting end of the bone and the cartilaginous framework of the auditory 
canal, suggests the possibility of a change akin to chondromalacosis (see 
p. 46) as the starting-point of the entire series of morbid phenomena. 

In all the five cases described in the present section, the lesions ob- 
served in the auditory canal presented every appearance of being primary 
in their nature, or, at all events, independent of any recognizable disease of 
the middle ear. In the following three cases, which I propose to classify as 



False Membranes in the Auditory Canal, 

the dependence of the lesions upon a primary disease of the middle ear, or 
upon the irritating presence of a foreign body, was so evident that it could 
scarcely escape the notice of even a superficial observer. It might there- 



DISEASES OF THE EAR. 99 

fore be expected that, in accordance with what I said at the beginning of 
this section, I should describe these conditions in the chapters relating to 
diseases of the middle ear. The conditions, however, to which I have ref- 
erence, are seen so seldom, and possess such a decided individuality, that I 
prefer on the whole to describe them in the present section, in connection 
with the more strictly independent affections of the auditory canal. 

The first case furnishes an instance of the development of a cord-like 
bridge of flesh in the auditory canal. The patient, a female, twenty-five 
years of age, and in good general health, presented herself for treatment at 
the New York Eye and Ear Infirmary, on the 30th of August, 1871. She 
stated that there had been a discharge from the left ear during the previous 
three years. On examination I found the outer orifice filled with a poly- 
poid growth. With Blake's snare I then removed in succession four dis- 
tinct polypoid masses, all of them growing from the walls of the auditory 
canal, and not connected, so far as I could discover, with carious bone. 

On the 6th of September I saw the patient a second time, and found 
that the stumps of the polypi removed on the 25th of August had already 
markedly increased in size. I used the snare a second time, and cauterized 
the remaining raw surfaces with nitrate of silver. 

On the 23d of September I examined the ear again and discovered that 
two of the stumps — situated opposite to each other, one on the upper, the 
other on the lower wall of the meatus — had coalesced so as to form a dis- 
tinct cord-like bridge of flesh, stretching from the upper to the lower wall 
of the meatus. Moderate stretching of this band with the probe failed to 
produce a rupture, and, being anxious to see whether it would shrivel up 
and disappear of itself, or what would become of it, I abstained from any 
further interference, and simply advised the patient to syringe the ear daily 
with lukewarm water. 

On the 4th of October I found that the fleshy band had perceptibly 
diminished in diameter. There was also very little discharge. 

On the 6th of December I found that the discharge had ceased entirely, 
and that the walls of the meatus were perfectly dry. The fleshy band had 
diminished to the proportions of a slender cord scarcely one millimetre in 
diameter ; and when touched with the probe it felt dry and stiff, as if it 
were made of parchment. The mass of granulation-tissue had undoubtedly 
become completely covered with epidermis, and then the process of con- 
traction, which is common to all newly formed connective tissue as soon 
as suppuration ceases, had reduced its proportions to those of a slender 
cord. 1 (The patient did not subsequently return.) 

In another case I had an opportunity of watching the same series of 
pathological changes take place on a much larger scale. The patient, a 

1 Dr. George T. Englemann, of St. Louis, has reported a very similar case in the 
Archiv fur Ohrenheilkunde, Vol. VI., p. 203. 



mmmmm^m^^m 



100 DIAGNOSIS AND TREATMENT OF 

rather dull boy of twelve, was brought to the New York Eye and Ear In- 
firmary by his parents, on the 9th of July, 1873. Three years previously he 
had passed through an attack of scarlet fever, but no discharge from the 
ear had been noticed until a short time before his visit to the Infirmary. 
On examination, I found the entrance to the canal blocked by quite a large 
mass of granulation- tissue. The removal of this mass by means of Blake's 
snare brought to view a dark body, which felt hard when touched with 
the probe, and seemed to be tightly wedged in between the anterior and 
posterior walls of the canal. Steady traction, by means of a steel hook in- 
troduced flatwise between the foreign body and the upper wall of the mea- 
tus, and then turned point downward as soon as the inner end of the hard 
mass bad been reached, brought it away entire. It proved to be a prune- 
pit of moderate size. Neither the boy nor his parents could account for 
its presence in the ear. That portion of the meatus in which the greatest 
breadth of the pit lay seemed to be larger than the natural size, while just 
beyond and just this side of the dilated portion the soft parts of the canal 
appeared to be swollen. 

Nine days later I saw the patient a second time. The inner limit of the 
dilated portion — corresponding to the junction of the inner and middle 
thirds of the osseous part of the canal— was then the seat of a ring-shaped 
mass of granulation-tissue, which encroached very decidedly upon the cali- 
bre of the meatus. 

Sixteen days later still (August 4th), I found the calibre of the canal al- 
most obliterated by this mass. Although the probe could still be passed 
through the centre of the obstructing granulations, the appearance pre- 
sented was as if the calibre of the canal had been completely obliterated at 
this point. 

During the following week three applications of chromic acid (in crys- 
talline form) were made to the central portion of the mass. This caustic, 
however, set up so much inflammation that I was obliged to abandon its 
use. The boy was not seen again until the 2d of September. The canal 
was then found to be perfectly dry, and the patient said that the discharge 
had ceased several days previously. The ring-shaped mass of granulation- 
tissue had become transformed into a solid cul-de-sac, completely obliterat- 
ing the calibre of the canal. The tissues were dry, smooth and firm, and 
no longer resembled granulation-tissue. In the centre of the mass, a small 
scab, about the size of the head of a pin, was visible. After this had been 
torn off, the probe could readily be pushed through to the broad part of 
the canal beyond. 

Efforts at dilatation, by means of small laminaria bougies, were kept up 
during the following two or three days, but they caused considerable pain 
and proved of no avail. On the 28th of September fuming nitric acid was 
freely applied to the centre of the mass. The pain caused by this applica- 
tion was only moderate. 



DISEASES OF THE EAR. 101 

G'A the 4tli of October I found that the acid had made quite a free 
opening in the mass. The application was not repeated, and yet the tis- 
sues forming the annular constriction continued to contract (centrifugally), 
and the calibre of the canal to enlarge, until, on the 22d of November, when 
I saw the boy for the last time, only a slight trace remained of the mass, — 
which, if it had been left to itself, would undoubtedly have formed a per- 
manent obstruction in the canal, in the shape of a diaphragm or false 
membrane. The discharge, which made its appearance soon after the ap- 
plication of the acid, had entirely ceased. Beyond the narrowed portion 
of the canal, which was very near its inner limit, the membrana tympani 
was plainly visible. Its lower half was perforated near the centre. 

The following case completes the picture which nitric acid spoiled in 
the preceding case : 

The patient, a female, twenty-six years of age, consulted me at the New 
York Eye and Ear Infirmary, on December 1, 1873. She had been some- 
what hard of hearing all her life. In childhood there had been a discharge 
from both ears, but during recent years there had not been any from the 
right one. In this ear the watch was heard only when pressed firmly 
against it. The left ear presented the ordinary appearance of an uncom- 
plicated chronic purulent inflammation of the middle ear. An examination 
of the right ear revealed the following condition : the meatus was nor- 
mal ; at its inner end it terminated in a smooth, parchment-like mem- 
brane, of uniform but slight concavity outwardly, and looking very much 
like a membrana tympani from which the malleus had been removed. 
When tapped with the probe this membrane gave forth quite a loud sound, 
such as is heard when a stiff piece of parchment is bent. It appeared to 
be considerably thicker than the normal drum-membrane, and, at every 
point of the periphery, passed without the slightest break or irregularity 
into the skin of the auditory canal. A superficial observer might very readily, 
I think, have taken this strange diaphragm for the membrana tympani. Its 
greater proximity to the external orifice, however, and the absence of the 
handle of the hammer, showed almost conclusively that, notwithstanding 
its dry, membranous character, it was not the di-um-membrane, but a new- 
formation of some kind. 

So far as its influence upon the hearing was concerned, such a mem- 
branous diaphragm could only act as an obstacle. I therefore had no hes- 
itation in making a free crucial incision through it. The angular flaps 
thus made showed very little disposition to retract. They were readily 
bent over toward the walls of the meatus, however, and thus a view of the 
deeper structures was obtained through the irregular opening. All that 
could be seen at that time was the red and moist mucous membrane of the 
promontory, situated about four or five millimetres beyond the plane of 
the false membrane. As an evidence of the vitality of the latter, I might 
mention the fact that, a very few minutes after the incisions had been made, 



102 DIAGNOSIS AND TREATMENT OF 

a glistening border of bloody serum was noticed along each of the cut 
edges of the angular flaps. The improvement then observed in the hear- 
ing, at least for conversation, was quite marked ; for the watch, the hearing 
distance was increased to four inches. 

At the next visit, a week later, the patient reported that there had been 
a constant discharge from the right ear since the day following the opera- 
tion. The perforation was then circular in shape, from three to four milli- 
metres in diameter, and through it the relations of the deeper parts could 
be distinctly made out. It was thus ascertained that the handle of the 
hammer was still entire, though adherent to and covered up at its tip by 
the tissues of the promontory. The short process of this ossicle could be 
distinctly recognized at the inner edge of the base of the false membrane. 

When last seen the patient still complained of a slight muco-purulent 
discharge, and no marked change had taken place in the condition of the 
parts. 

The two preceding cases each throw light upon the other. In that of 
the boy, for example, there can hardly be any reasonable doubt that if I 
had not interfered vigorously with nitric acid, a false membrane or dia- 
phragm, similar in every respect to that which was observed in the case of 
the woman, would have developed at the seat of the constriction. On the 
other hand, had I not previously watched the peculiar behavior of the 
granulation-tissue in the boy's case, and also in that of the first case (p. 
99), I might have experienced difficulty in explaining the presence of such 
a parchment-like diaphragm in the osseous portion of the auditory canal. 
In all three cases the different steps of the process were essentially the 
same. Under the stimulus of some irritating cause, granulation-tissue was 
produced. Two granulating surfaces met at a time when there was not 
a sufficient current of fluid secretion to prevent them from uniting ; and 
they accordingly united into a single mass. The original irritating cause 
had by this time been withdrawn, and the absence of a free secretion of 
pus from the surface of the mass of granulations, opened the way for the 
growth of a protective covering of epithelium from the surrounding healthy 
skin. As soon as the mass had once become covered with skin, rapid con- 
traction and atrophy of all the connective-tissue elements followed, until 
finally nothing remained but two horny epidermal layers separated from 
each other by a thin sheet or cord— as in the first case— of connective 
tissue, poorly supplied with blood-vessels, and apparently not at all fur- 
nished with sensory nerves. 

The false membranes observed in the preceding cases were provided 
with blood-vessels and represented each an integral portion of the living 
body ; that observed in the following case can only be looked upon in the 
light of something cast off and already dead, though still mechanically con- 
nected with the body. 



DISEASES OF THE EAR. 103 

The patient, a female, fifty years of age, consulted me in the summer 
of 1876, for deafness of slight degree, referable chiefly to the left ear, and 
of about one year's duration. Examination with the speculum and reflected 
light, revealed the following condition of things in the left ear : In the 
osseous portion of the external auditory canal, at a point about one-third 
of an inch from the drum-membrane, a membranous structure completely 
occluded the canal. To the eye, this membrane presented all the appear- 
ances of ordinary cast-off cuticle. At no point did it show any evidence of 
being provided with blood-vessels. When touched with the probe it 
yielded to the pressure in precisely the same elastic manner as would any 
thin membrane like the cuticle, when separated from its underlying con- 
nections. The peripheral portion of the membrane was carefully tested 
with the probe at all points of the circumference, for the purpose of ascer- 
taining the nature of its attachment to the skin of the external auditory 
canal. At every point it was found to be continuous with the cuticle of the 
neighboring skin. The plane of the membrane was nearly at right angles 
to the axis of the canal. 

In order to ascertain the exact condition of the deeper parts of the ear, 
and also, at the same time, for the purpose of removing from the canal 
what could only be considered as a hinderance to the perception of sound, 
I made a crucial incision through the membranous diaphragm, and then, 
with the forceps, tore away the greater part of the remaining segments. At 
the points where the attached membrane had been torn off, no evidence of 
any line of attachment remained, beyond at most a diffuse redness of the 
skin. The drum-membrane beyond presented a fairly normal appearance, 
and the hearing was somewhat improved by the removal of the obstacle. 

This case, which is entirely different in its pathogenesis from the one 
last reported, derives its chief importance from the light which it throws 
upon the question of horizontal or surface motion in the epidermis of the 
membrana tympani and skin of the external auditory canal. That such a 
motion exists on the outer surface of the drum-membrane has been known 
for several years. Every aural surgeon who has had occasion to perform 
paracentesis of the membrana tympani has observed how from day to day 
the scab resulting from his incision moves from its original situation in the 
posterior half of the membrane, midway between the umbo and the peri- 
phery, toward the latter, and eventually, in its outward course, leaves the 
di*um-membrane entirely. The same motion has been observed in the ex- 
ternal auditory canal in the immediate vicinity of the membrana tympani. 
Dr. Burnett, in his " Treatise on the Ear" (p. 46), speaks of this outward 
movement of the skin of the external auditory canal as affording an ex- 
planation of the way in which the superabundant cerumen is extruded from 
the canal. This surface movement, then, of the epidermis of the drum- 
membrane and external auditory canal, furnishes, I believe, an explanation 



104 DIAGNOSIS AND TREATMENT OF 

of the presence — in the case narrated above — of a cuticle-like, membranous 
diaphragm in the outer canal of the ear. This membrane, according to 
this theory, would represent a desquamation — probably the result of an 
acute congestion of the parts — of the entire epidermal coat of the drum- 
membrane. That part of the cuticle of the membrana tympani which had 
separated from the underlying living epithelial cells must, in the present 
instance, have retained (at all points of the circumference) its connections 
with the neighboring healthy cuticle of the external auditory canal. The 
surface motion known to exist in the cuticle of the deeper portion of the 
canal extends without doubt throughout the entire canal. Hence, in the 
present case, after the cuticle had separated from the drum-membrane, the 
centrifugal motion of the remoter parts of the separated membrane — due 
to the traction exerted by the outwardly moving healthy cuticle of the ex- 
ternal auditory canal — must have produced at first merely a state of ten- 
sion (equilibrium) in the central portions of the cuticular membrane. At 
a later moment, however, this outward motion of the healthy cuticle must 
have exerted a symmetrical outward traction upon the cuticular membrane, 
eventually lifting it completely off the underlying membrana tympani. 
That in this particular case a rupture did not occur at some point must be 
ascribed simply to the fact that probably all things conspired to favor a 
separation of the desquamated cuticle in its entirety. After the act of sepa- 
ration had once taken place, there was no reason why the separated cuticle 
(then an independent diaphragm) should not remain unbroken, until acted 
upon by some force from without. If different parts of the healthy cuticle 
of the external auditory canal travelled outward at different rates of speed, 
we might look for a rupture, or at least for a distorted cuticular diaphragm. 
The flatness of the membrane, in the present case, and the inclination of 
the plane which it occupied, to the axis of the meatus, would rather favor 
the view that the rate of speed is the same for all parts of the canal. 

Further observations and experimental researches will doubtless soon 
determine accurately all the facts connected with this peculiar horizontal 
cuticular motion, analogous to the growth of the nail, which may be looked 
upon as a cuticular structure. 



Syphilitic Ulcers and Condylomata. 

To judge from the accounts of recent writers on otology, and also from 
my own experience, cases of syphilitic disease of the auditory canal are 
comparatively rare. I have seen but three instances in which the lesions 
observed in the meatus deserved to be classed as distinctively syphilitic. 
In the first one the picture presented was, I confess, not very striking ; in 
the other two, however, the idea of syphilis was suggested at almost the 
first glance at the outer orifice. 



DISEASES OF TIIE EAE. 105 

The first case was seen on the 8th of April, 1874. The patient, a man, 
forty-four years of age, stated that he "caught cold" three weeks previ- 
ously, but did not notice anything wrong about the ear until about two 
weeks later. The left ear then began to ache, and very soon afterward a 
discharge appeared at the orifice of the auditory canal. From that time to 
the day on which I first saw the patient, the discharge, he said, had been 
constant. On examination, I found the left membrana tympani red, very 
much swollen, and perforated anteriorly and inferiorly. The lower wall of 
the outer half of the meatus was ulcerated for a distance of about half an 
inch. The ulcer extended outward upon the auricle, and its limits were 
everywhere quite sharply defined. An examination of the throat revealed 
the existence of well-marked syphilitic lesions, and, on questioning the pa- 
tient, he admitted that he had had a chancre one year previously. (This 
case was not seen again.) 

As already mentioned, the lesions observed in this patient's ear were 
not of such a character as to suggest at once a syphilitic origin. It was 
only after the throat had been examined that the thought of a common 
origin for the two sets of lesions suggested itself to my mind. And yet, if 
we reflect for a moment, we shall be obliged to admit that the development 
of a well-defined ulcer in the auditory canal, after a discharge from the 
deeper parts of the ear had been going on for only one short week, was a 
very unusual phenomenon. In children the external auditory canal is very 
apt to become ulcerated by the constant flow of an irritating secretion over 
its surface ; in adults, however, this rarely happens, and then almost always 
in connection with a chronic discharge from the ear. In the present case 
a comparatively large and well-defined granulating area or ulcer had devel- 
oped in a canal which presented almost no other evidence of active inflam- 
mation, and which had been subjected to no other irritating influence than 
that which may have been exerted by the flow, for the period of a week, of 
a purulent fluid over its surface. Furthermore, the discharge was by no 
means copious, as we should rightly expect it to be if it had been the sole 
cause of the extensive ulceration observed. These are the points which seem 
to me to justify the view that this ulcer was a true syphilitic ulcer or gum- 
mous degeneration. 

The second case was seen on the 7th of August, 1878. The patient, a 
man, twenty-eight years of age, of strong frame and apparently vigorous 
constitution, stated that during the month of February he first noticed a 
discharge from the right ear. It came on without pain, lasted for a few 
weeks, and then ceased of its own accord, without treatment. In the early 
part of the summer the discharge returned, and from that time forward it 
had been a constant symptom. He had experienced no difficulty in hear- 
ing, but for a short time before I saw him he had noticed some soreness of 
the affected ear. On examination I found the following conditions : the 
orifice of the right meatus was almost completely obliterated by the pres- 



106 DIAGNOSIS AND TKEATMENT OF 

ence of an elevated patch of what seemed, at first sight, to be simple granu- 
lation-tissue ; the dividing line between this patch, which completely en- 
circled the orifice, and the healthy skin of the auricle, was sharply drawn, 
the edges of the elevated portion being quite abrupt. When the auricle 
was pulled upward, backward, and a little outward, the flattened patch 
opened in the centre and displayed a narrowed entrance to the auditory 
canal beyond. At the same time fissures became visible in the outer sur- 
face of the patch. "When the auricle was allowed to resume its natural po- 
sition, these fissures completely disappeared, and the central opening be- 
came converted again into a mere depression in the centre of the patch. 
When examined more closely, this circular patch, which seemed to be com- 
posed of granulation-tissue, proved to be made up, in reality, of very nu- 
merous minute vegetations or papillomata, the majority of which were of a 
pale pinkish hue, while a few presented a decidedly red color. A watery 
discharge oozed from the lower part of the elevated patch. The fissured 
appearance, observed when the parts were put upon the stretch, was found 
to be due to the fact that the minute papillomata sprang in groups from 
rather broad trunks, and the fissures corresponded with the spaces which 
separated these larger trunks. Just inside the orifice were found a few 
growths which were quite large in comparison with the greater number, — 
as large, e.g., as a hemp-seed, or even larger. The external auditory canal 
itself, so far as the eye could see with the aid of a small speculum and re- 
flected light, was filled with similar vegetations. Between the larger masses 
were numerous smaller and more pointed growths, like those observed at 
the orifice. When touched with the probe, the larger of these growths 
were found to be considerably harder than ordinary granulation-tissue. 
Some of them looked precisely like (on a smaller scale, of course) the warts 
seen on the fingers of young children, the skin covering them being pale 
and tough like natural skin. The smaller papillary growths, and one or 
two of the larger ones near the orifice of the canal, were less firm in struc- 
ture, and bled readily when they were manipulated with the probe. The 
membrana tympani was not visible. The gland lying upon the mastoid 
process of the same side was enlarged to such an extent as to cause a visi- 
ble swelling in this region. The occipital glands were also moderately en- 
larged. A diffuse discoloration of the skin, with desquamating surface, was 
observed on' the hairy scalp, and also to a slight extent on the forehead of 
the left side. Two well-marked mucous patches occupied the left half of 
the velum palati. On questioning the patient it was ascertained that he 
had contracted the primary lesion about fifteen months previously. 

Treatment was not begun until September 4th. It consisted in daily 
inunctions of mercury (about a drachm of Squibb's oleate of mercury [5 
per cent.]), and also its internal use (one thirty-second of a grain of the bi- 
chloride three times a day). The larger vegetations which were within 
reach were snipped off with the scissors ; the smaller ones were touched 



DISEASES OF THE EAE. 107 

with nitric acid. The patient was simply instructed to keep the ear clean 
by syringing it out from time to time with warm water. 

The subsequent progress of the case may be briefly stated as follows : 

September 26th. — The dose of the bichloride was increased to-day to 
one-sixteenth of a grain three times a day. The patient was also given 
some calomel with which to dust those vegetations which were within his 
reach. 

October 2d. — Patient feels better in every way, and says that the 
otorrhcea is diminishing in quantity. The patch of vegetations around the 
orifice of the external auditory canal has perceptibly diminished in height 
and in vividness of color. 

October 23d. — Patient has gained thirteen pounds in weight since the 
4th of September. He has been very faithful in using the remedies pre- 
scribed. The squamous eruption on his forehead has almost disappeared. 
The orifice of the external auditory canal has been steadily increasing in 
size. Very little change, however, is perceptible in the condition of the 
deeper portions of the canal. By aid of the probe it was ascertained to- 
day that the innermost section of the meatus, close to the membrana tym- 
pani, was smooth and apparently free from vegetations. The " mucous 
patches " are still visible on the velum. Iodide of potassium is to be added 
to the bichloride mixture, in the proportion of ten grains to each dose. 

November 6th. — The wart-like growths in the external auditory canal 
have become less prominent ; they encroach less upon the calibre of the 
canal, and the intermediate bright red pointed condylomata have lost their 
bright color and well-defined outlines. Nitric acid (undiluted) applied 
firmly to one of the more prominent excrescences near the external orifice. 
The pain which followed lasted but a minute or two, and then entirely dis- 
appeared. Appetite good. No evidence of sponginess of the gums. 

November 13th. — Application of nitric acid repeated to-day. The ori- 
fice is now increasing in size quite perceptibly, and the deeper condylo- 
mata — simply under the influence of the constitutional treatment — have 
now shrunk away to mere elevations of the skin. The discharge is also 
very much less than at first. The inunctions are still kept up. The im- 
provement in the condition of the meatus has been more marked during 
the past week than during any previous week since treatment was begun. 
No appreciable change in the condition of the " mucous patches " on the 
soft palate. Dose of potass, iodid. increased to twenty grains three times 
a day. 

November 20th. — Patient has now gained twenty-six pounds in weight. 
The discharge from the ear has ceased, and almost every trace of the con- 
dylomata has disappeared. Membrana tympani entire. 

In the third case, the conditions observed in the auditory canal were 
in many respects different from those which I have just described. The 



108 DIAGNOSIS AND TREATMENT OF 

patient, a woman, twenty -five years of age, was under treatment at the time, 
for syphilitic disease of the vulva. The first symptoms referable to the ear 
were noticed about eight weeks previously. The ear became painful, and 
soon a discharge took place from the external auditory canal. Three weeks 
previously the ear again became painful, and relief was only obtained after 
a free incision had been made through the mastoid integuments ; leeching 
and other simple measures having failed to quiet the pain. At the time I 
saw her the meatus was obstructed by the presence of several wart-like 
growths, situated on opposite sides of the canal, and bathed with a thin 
watery pus. These growths were very firm in texture, being covered ap- 
parently with true skin. The largest was equal to a pea in size, and sprang 
from the anterior wall of the canal, near the orifice, by a broad base. 
The drum-membrane and the deeper parts of the canal were concealed 
from view by these growths. By aid of the probe, however, I ascertained 
that the latter were not connected with any fistulous opening in the bone 
or with any superficial spot of caries. (The case was not seen again.) 

At the beginning of the present section I stated that in two cases of 
syphilitic disease of the auditory canal — the two last described — the idea 
of syphilis suggested itself to my mind at almost the first view. In other 
words, the lesions presented to the eye were so characteristic, so different 
from those observed in non-syphilitic cases, that one could scarcely fail to 
be struck with their individuality. This opinion, I should state, is directly 
in conflict with that expressed by Schwartze. In a paper published by 
him in 1369, ] he states that in the auditory canal polypoid granulations 
undoubtedly occur, which must be considered as a local manifestation of 
constitutional syphilis. "As granulations of this character, however, are 
exceedingly common in non-syphilitic individuals affected with a purulent 
inflammation of the ear, it becomes a very difficult matter to decide, in a 
given case, whether the growths are or are not of a specific nature. From 
the anatomical examination alone, no definite conclusion can be drawn. 
The characteristic papillary structure of the tumor, which sometimes pre- 
sents the appearance of a perfectly developed condyloma, is also observed 
in cases where syphilis is not to be thought of for an instant." As no ma- 
terial modification of this view is put forth in his recent treatise, 5 1 assume 
that his opinion still remains substantially the same as it was in 1869. It is 
quite possible that the two cases of syphilitic "granulations" which came 
under my observation, were exceptionally well-marked types of the disease. 
This view, however, is rendered improbable by the fact that other authorities 



1 Archiv fur Ohrenheilkunde, Yierter Band. Wurzburg, 1869. Pages 253 et seq. 

2 H. Schwartze : The Pathological Anatomy of the Ear. Translated by J. Orne 
Green, M.D. Boston, 1878. 



DISEASES OF THE EAE. 109 

(Stoehr, 1 Gruber, 3 and Depres 3 have reported quite a large number of cases 
in which well-characterized lesions of syphilis were observed in the audi- 
tory canal. I have also never seen, in non-syphilitic individuals, lesions 
which resembled in any but a very superficial degree those which I have 
described above. It seems to me, therefore, that Schwartzes statement 
is too sweeping in its character, and that it may be set down as a fact that 
well-defined lesions of constitutional syphilis may occur as well in the ex- 
ternal auditory canal as in other parts of the body. 



Fokeign Bodies. 

If we exclude such bodies as sequestra of bone, hardened masses of 
cerumen, calcareous bodies, and the so-called cholesteatomata, — which are 
essentially laminated masses of epithelium, — we may say that foreign bodies 
in the auditory canal are not of frequent occurrence. Thus, for example, 
out of 1,652 cases Dr. Blake found (in 1873) foreign bodies in the meatus 
sixteen times (about one per ceht.). According to the statistical report of 
the New York Eye and Ear Infirmary for 1878, the proportion was about the 
same, viz., 30 cases out of 2,784. My own records show a still smaller pro- 
portion, viz., about half of one per cent. With regard to the ages of these 
individuals, I find that 18 out of the 29 cases seen were under twenty years 
of age. Between the ages of two and five, there were 4 cases ; between 
five and ten, 10 ; between ten and fifteen, 2 ; between fifteen and twenty, 2. 
The foreign bodies found in the individuals who were under twenty years 
of age were quite different in character from those found in the adults. 
They comprised pebbles, glass beads, a cherry-pit, a prune-pit, ordinary 
beans, both black and white, a coffee-bean, a grain of corn, a piece of lead 
from a lead-pencil, a piece of slate pencil, and small rolls of paper. These 
articles, as will be noticed, are all such as a child would be likely to put 
into his own ear or into that of another child. Those articles found in the 
ears of adults were exclusively such as would be likely to find their way 
into the canal through accident or forge tfulness, or else wholly without hu- 
man agency. In one case, for example, it w T as a fly ; in a second, four flies 
were found ; in a third, two living larvae of the house-fly ; in a fourth, a 
cockroach or Croton bug ; in a fifth, a young bed-bug ; in two others, a 
stiff hair was found, sprung like a bow between the wall of the canal and 
the drum-membrane ; finally, in five cases, a forgotten mass of cotton-wool 
was in each instance found impacted between the drum-nieinbrane and the 
anterior wall of the meatus. 

1 Archiv fur Ohrenheilkunde, 1869. Fiinfter Band, S. 130 et seq. 

3 Ueber Syphilis des Gehororgans. Wiener Med. Presse, 1870. Nos. 1, 3, and 6. 

3 Annales des maladies de l'oreille, etc. December 31, 1878. 



I^^^^^BH 



110 DIAGNOSIS AND TREATMENT OF 

Symptomatology. — In many of the cases which come under observation, 
the patient complains of no symptoms whatever. Some mischievous play- 
mate, or the boy himself, has introduced a bean, or a bead, or some other 
small object into the canal, and the parents are afraid that some harm may 
come to their child if the foreign body is allowed to remain in the ear. It 
is this fear on their part, and not any deafness or suffering on the part of 
the child, which usually leads them to consult a physician. Now and then 
the rough manipulations of medical men who attempt to remove a foreign 
body from the ear without seeing exactly what they are doing, convert a 
simple case of this kind into one of a very complicated and painful nature. 
During the years 1870 to 1874 I saw several cases of this kind, but during 
recent years I have not seen a single instance, and am disposed to consider 
this fact as an evidence that general practitioners, as a body, are more 
willing than formerly to entrust the management of these cases to the 
specialists. 

In another class of foreign bodies, the patient experiences well-marked 
symptoms. Thus, for example, in both the cases where a hair was found 
sprung between the membrana tympani and the wall of the canal, the sen- 
sation of pressure or fulness in the affected ear was sufficiently marked to 
lead the patient to consult a physician. In another case, the patient com- 
plained of a crunching noise in one ear. It was not constant, but was noticed 
chiefly whenever he ate anything. On examination, a piece of dried cuticle 
was found lying against the drum-membrane, between it and the anterior 
and lower wall of the canal. Although from an anatomical standpoint it is 
difficult to comprehend how the motions of the jaw can exert traction 
upon either the membrana tympani or the skin lining the extreme inner 
end of the auditory canal, the fact remains that the opening and shutting 
of the mouth may produce sufficient motion in these parts to cause a slight 
friction between the foreign body and the drum-membrane. In the cases in 
which dead flies were found in the meatus, the patients had experienced no 
unusual symptoms, and were unable to say when or how these insects had 
found their way into the ear. As both patients were affected with a chronic 
purulent inflammation of the middle ear, it is quite possible that the flies 
were attracted to the ear by the odor of the discharge. The presence of 
living larvse of the house-fly in the canal of another patient, also a sufferer 
from chronic purulent inflammation of the middle ear, is probably best ex- 
plained by assuming that the eggs were actually deposited in the auditory 
canal by a fly, probably while the patient was asleep. The Croton bug and 
the bed-bug also undoubtedly effected an entrance when the patients were 
asleep, for in neither of the cases could the patient state at what exact time 
the insect entered the canal. At a certain time, however, both patients be- 
came aware that some living creature had got into the ear, as a sensation 
of something moving in the canal was felt by each of them. The Croton 
bug was dead when I extracted it ; the bed-bug was alive, and, when first 



DISEASES OF THE EAE. Ill 

seen, presented the appearance of a small mass of brownish ear-wax adhe- 
rent to the upper part of the drum-membrane. 

Finally, in those cases in which unskilful and unduly violent efforts had 
been made to remove the foreign body, before the patients finally came under 
my observation, the prominent symptoms were : marked pain and tenderness 
in the region of the ear, a bloody discharge from the canal, and a terrible 
dread of having the ear touched. In one of these cases I found the pebble 
lying partly in the meatus and partly in the middle ear, the drum-membrane 
having apparently been lacerated by the efforts previously made to remove it. 
In another instance the bony surface of the canal was found to have been laid 
bare. In a third case the external orifice was found to be in such a swol- 
len condition that the diameter of the foreign body beyond must have been 
at least twice as great as that of the canal through which it would have to 
pass, while being extracted. Were it not for these, now fortunately rare, 
cases, the symptomatology of foreign bodies in the external auditory canal 
might almost be omitted altogether. 

I should perhaps mention the fact that women sometimes consult a phy- 
sician for the purpose of having an imaginary foreign body (generally a 
pin) removed from the ear. I have seen two or three such cases, and have 
observed in each instance that the patient seemed to be annoyed by my 
assurances that the auditory canal was perfectly natural and contained noth- 
ing that did not belong there. Judging from their actions, after the re- 
sults of the examination had been communicated to them, I have no doubt 
that they ascribed my failure to find the foreign body to lack of sufficient 
skill in examining the ear. 

Treatment. — Hard substances, like beads, j:>ebbles, or buttons, if they do 
not cause pain, and if they are not actually impacted in the auditory canal, 
may be allowed to remain there undisturbed for a reasonable length of time. 
In one of my cases, for example, a glass bead of large size had remained 
twelve years in the canal without doing the slightest damage that I could 
discover. As the foreign body, however, may change its position and be- 
come wedged in between the drum-membrane and the anterior wall of the 
canal, and as an intercurrent infiammation of either the meatus or the 
middle ear might be seriously complicated by the presence of such a for- 
eign body in the canal, it is better not to delay its removal any longer than 
is necessary to ensure a successful result. If the body is impacted in the 
canal and is causing pain, the sooner it is removed the better. If the opera- 
tion is postponed, the outer portion of the canal may become swollen, and 
the task of extracting the foreign body may thereby be rendered materially 
more difficult. In the case of substances like dried j)eas and beans, which 
may swell up in water to fully twice their original size, it is important to 
abstain from using the syringe ; or else, if we fail by means of it to remove 
the foreign body, we should proceed, without further delay, to extract it by 
means of instruments. 



112 DIAGNOSIS AND TREATMENT OF 

Small bodies, which simply lie in the canal without being impacted be- 
tween its walls, may be removed by means of such instruments as the slen- 
der forceps, the curette, or a bent probe, or by means of the syringe. As- 
suming that the physician has illuminated the canal by means of reflected 
light, and that he actually sees such a small foreign body lying in the au- 
ditory canal, I can think of only two valid reasons why he should rise from 
his seat, get ready a vessel of warm water, and proceed to syringe out the 
foreign body. These are, the lack of the proper instruments and the lack 
of a steady hand. If the foreign body is of sufficient size to fill the canal, 
or to press against its sides at two or more points, the use of the syringe 
seems to me to be thoroughly irrational and unpractical. What is required 
in such a case is a " force from behind/' and not one that spends itself 
upon the outer surface of the foreign body, and thus tends to drive it deeper 
down into the canal. If the shape and position of the body are such that 
we may with some degree of confidence hope to extract it by seizing it 
directly with the slender forceps, this plan may be adopted. But it is far 
better not to make such an attempt, unless we are quite confident of suc- 
cess ; for if we lose our grasp upon the body, we may be almost sure that 
we shall drive it a little beyond the position which it previously occu- 
pied, and thus render the problem of removal correspondingly more diffi- 
cult. The better plan is to explore the circumference of the foreign body 
with the probe, and thus ascertain whether there is not some point where 
it is separated by a certain amount of space from the wall of the meatus. 
This is the point at which we should introduce the instrument by means of 
which we intend to bring the desired vis a tergo to bear upon the foreign 
body. In the case of a roundish body like a cherry-pit, a pea, or a bean, 
we shall undoubtedly fail to find such a point. Under these circumstances, 
if we desire to bring a similar force to bear upon the impacted body, we 
must employ an instrument that is both slender and strong : slender enough 
to force its way between the foreign body and the skin of the canal, with- 
out injuring the latter, and yet strong enough, after it has once been pushed 
inward the requisite distance, to exert a decided downward and outward 
pressure upon the inner end of the mass. The smaller curette and a deli- 
cate steel hook are almost the only instruments which 1 have used for 
the purposes we are now considering. The curette is made of steel and 
has been sufficiently described in an earlier section. The hook should also 
be made of steel, but the shank should be tempered and not left in a 
malleable state like that of the curette-shank. In introducing the curette, 
which must first be slightly bent flatwise, we must make its ring-shaped end 
describe an arc of a rather small circle, or we shall cause the patient unne- < 
cessary pain, and perhaps fail to carry the end of the instrument beyond 
the foreign body. In introducing the hook we must follow a somewhat 
different principle : as we push the instrument farther and farther inward, 
we must make the end of the hook proper hug the foreign body constantly. 



DISEASES OF THE EAR. 113 

By pursuing this plan we shall know instantly when the instrument has 
reached the inner end of the foreign body ; for the hook, no longer meet- 
ing with the resistance offered by the side of the obstructing mass, will at 
that very moment perform the rotatory movement which the pressure of 
our fingers has tended to give it. We must not allow it, however, to per- 
form more than a quarter of a turn, for fear of bringing the free end 
in contact with the walls of the canal. When the hook has performed this 
quarter revolution, we should withdraw it cautiously but firmly, and thus 
dislodge the impacted foreign body. If that portion of the canal which is ex- 
ternal to the foreign body is very much swollen, it will be found necessary to 
first dilate it gradually, by means of a series of well-polished, conical spec- 
ula, or by means of cotton-wool wound tightly around the end of a cotton- 
holder, and moistened with vaseline or oil. In the case of older children 
it will probably not be found necessary to administer an anaesthetic ; and 
even in the younger ones I have only five times found it impossible to pro- 
ceed without the administration of sulphuric ether. Again, let me empha- 
size the importance of carrying out all these manipulations only when the 
canal is perfectly illuminated. 

The after-treatment in the graver cases is based upon the same princi- 
ples as those which govern the treatment of other acute inflammations of 
the canal or of the middle ear. In the simpler cases no after-treatment 
whatever is required. 

Those who are interested to learn something about the thousand and 
one ingenious methods which have been devised for removing foreign bodies 
from the external auditory canal, will find them fully described in Poulet's 
treatise on Foreign Bodies in Surgical Practice, 1 and in the general treatises 
of Roosa and Burnett. I have had no personal experience with these 
methods, and may therefore be excused from discussing their merits and 
demerits. 

Wounds. 

Injuries to the external auditory canal are, according to my experience, 
of comparatively rare occurrence. I have seen but three cases, and they 
were all of minor importance. In one of these the patient had introduced 
the rather pointed end of a pen-holder into the right ear, just as he rose 
from his seat to get something at the other end of the room. Passing too 
near an unusually high stove he suddenly felt a sharp pain in the right ear, 
as if a pointed object had been violently driven into it. Slight bleeding- 
followed, and the patient almost at once experienced a decided sensation 
of faintness, which lasted, however, but a short time. For a period of five 
days the ear gave him scarcely any trouble, and then it began to be de- 

: A translation of it forms a part of the present series of publications ("Wood's Li- 
brary of Standard Medical Authors). 
8 



114 DIAGNOSIS AND TREATMENT OF 

cidedly painful. About a week later still I had an opportunity of examin- 
ing the ear, and then found that an abscess had formed in the posterior 
wall of the canal, not far from the external orifice. From the appearances 
presented to the eye there could be no reasonable doubt that a distinct 
collection of pus existed at this spot. The patient, however, declined to 
have it lanced at that time, and I never saw him afterward. 

In the second case it was not ascertained exactly how the injury was 
received, owing to the fact that the patient was intoxicated at the time. 
The blow or the fell, however, produced unconsciousness for a short time, 
and when the patient recovered his senses he observed that blood was es- 
caping quite freely from the right ear. The accident occurred on the 9th 
of March, 1875, and from that time until the day on which I first saw him, 
viz., March 13th, an intermittent, but in the main abundant, hemorrhage 
had continued. On examination, I found a rather deep irregular wound 
in the cartilaginous wall of the canal, a short distance from its junction 
with the osseous portion. The bleeding had at that time ceased, and as 
the patient seemed to be free from pain, I advised him simply to leave the 
ear alone. Four days later I found the wound healing naturally by gran- 
ulation. 

In the third case the rib of a steel umbrella frame had been accidentally 
thrust into the external auditory canal, causing quite a small lacerated 
wound. Nevertheless the hemorrhage was quite free ; and, even after the 
lapse of twenty-four hours, I found the blood still trickling from the ear in 
a steady stream. Upon the introduction, however, of a very small piece of 
styptic cotton, the hemorrhage instantly ceased. 

The persistent bleeding which seems to characterize these lacerated 
wounds of the external auditory canal, is undoubtedly to be attributed k> the 
fact that those blood-vessels which pierce the cartilaginous framework — as 
many of them do — are not capable of contracting and retracting beyond a 
very limited extent ; their physical relations being essentially the same as 
those of the blood-vessels which traverse bony structures. 



New-Growths. 

Hyperostosis; Exostoses; Bony Closure. 

Both forms of hypertrophy of the osseous portion of the external audi- 
tory canal — the diffuse (hyperostosis) and the circumscribed (exostosis) — 
are by no means rare affections. As the child at birth has simply a rudi- 
mentary osseous canal, a mere ring of bone (the annulus tympanicus), we 
may safely assume that an exostosis or a diffuse hypertrophy of the bony 
canal is never a congenital but always an acquired condition. Out of thir- 
teen individuals in whose auditory canals I found hypertrophy of the bone 



DISEASES OF THE EAK. 115 

(in the form of exostoses ' ) the youngest was twenty-two years of age. In two 
cases I was able to trace the development of well-marked exostoses to the 
local irritation accompanying a purulent inflammation of the middle ear. A 
symmetrical hyperostosis, however, is a much commoner result of this local 
irritation. The resulting stenosis, or narrowing of the calibre of the canal, 
is sometimes so great that it is impossible to see the drum-membrane and 
deeper parts of the canal. In a large proportion of the cases of exostoses, 
however, no exciting cause whatever can be found. The presence of the 
bony tumors is discovered by accident, and their development seems to 
take place independently of any appreciable local irritation. Syphilis, gout, 
and rheumatism are mentioned by some authors as predisposing causes, but 
I have not been able, in a single instance, to trace such a connection. 

One of the most interesting questions connected with these bony 
tumors, relates to their rapidity of growth. So far as my own experience 
goes, I can throw but little light upon this important question. All but 
three of the patients were seen only once. In each of these three cases the 
ear was examined repeatedly during a period of several years, and it was 
clearly established that the bony tumor was slowly but steadily increasing 
in size. In the first case (that of a young girl, about eighteen years of age) 
the new-growth of bone took place in the form of a symmetrical encroach- 
ment upon the calibre of the inner end of the osseous canal. At first this 
stenosis was slight, and the deeper parts could still be seen under good 
illumination. The drum-membrane had been entirely destroyed ; at one or 
two points in the middle ear, exposed bone was felt with the probe ; near 
by were areas of granulation-tissue, and there was a constant flow of pus 
over the walls of the canal. In less than three years the hyperostosis had 
made such progress that it was utterly impossible to see anything of the 
deeper parts of the ear through the contracted canal. In this case the 
growth of bone seems to have been a gradual one, and if it had continued 
at the same rate, complete obliteration of the canal, at the region of the 
stenosis, in the course of two or three years more, might have been safely 
predicted. This case passed out of my hands, and I am unable to report 
its subsequent progress. In another case, however, three or four large, 
confluent (if I may be permitted to use the term) exostoses developed in 
the comparatively short period of three years, and then made no further 
progress during the following two years. When the exostoses ceased 
growing, the diminution in the size of the canal was so great that I could 
barely pass a slender silver probe through the narrowest part. That no 
further diminution in the size of the canal took place during the next two 
years, was shown by the fact that I was still able at the end of that time to 

1 I have not thought it worth while to ascertain in what proportion of the cases of 
chronic purulent inflammation of the middle ear stenosis of the auditory canal from 
diffuse hyperostosis of the bony portion occurs. It is by no means an uncommon 
condition, however, in this form of ear disease. 



116 DIAGNOSIS AND TREATMENT OP 

pass the same probe through the narrow part of the meatus. I watched 
this case with considerable interest, fully expecting that the previous rate 
of growth of the exostoses would be maintained, and that the resulting ob- 
struction to the discharge of pus from the middle ear would necessitate an 
operation. As the patient (a drygoods clerk, thirty-five years of age) 
promised to come and see me as soon as he observed any material change 
in the condition of his ear, and as I have not seen him for about three years, 
I think it quite probable that no further growth of the bony masses has 
taken place during this period. 

Finally, in a third case, the rate of growth of the exostoses was appar- 
ently more rapid. The patient, a physician, thirty-four years of age, had 
always heard well, and had never experienced any unnatural sensations in 
either ear, until toward the end of 1871. He then, for two or three succes- 
sive days, experienced severe pain in the right ear, and Dr. Hackley, an 
experienced aurist, who examined the ear, after the severe pain had sub- 
sided, found in the meatus a circumscribed swelling which presented the 
appearance of a furuncle that either had not yet reached maturity, or had al- 
ready begun to subside. In September, 1872, about a year after this condi- 
tion of the right auditory canal had been observed, the patient consulted me 
for a troublesome tinnitus in the same ear. On examination I found the canal 
narrowed by the presence of two broad-based exostoses, situated exactly 
opposite each other, the one on the anterior, the other on the posterior 
wall, close to the junction of the cartilaginous with the osseous part of the 
meatus. Deeper in was a third exostosis, which overhung the drum-mem- 
brane, and apparently pressed against it. Smaller exostoses, occupying 
almost the same positions as those observed in the right ear, were found in 
the left meatus. 

In March, 1873, I examined both ears a second time, and found that 
the exostoses in the right auditory canal, at least the two outer ones, had 
increased noticeably in size. Their summits approached within a milli- 
metre of each other, and the outlines of the walls of the canal presented a 
perfect resemblance to the old-fashioned hour-glass. On the left side, ap- 
parently no change had taken place in the size of the bony tumors. 

In October, 1876, I examined the patient for the third time, but could 
find no evidence of further growth on the part of the exostoses in either 
meatus. 

It seems reasonably clear, therefore, that there is no fixed law govern- 
ing the growth of these exostoses. At one time they increase in size at a 
relatively rapid rate, and then, for a period of years, without any percepti- 
ble change in the condition of the immediate surroundings, they show no 
further signs of growth. An instating purulent discharge seems to be an 
exciting cause of their growth in many cases, and yet in others {e.g., the 
last case mentioned) the growth of bone proceeds without any demonstrable 
exciting cause. 



DISEASES OF THE EAR. 117 

The prevailing shape of the exostoses that I have seen has been that of 
a hemisphere or low, broad-based cone. I have only twice seen a distinctly 
pedunculate exostosis, and in only one of these cases was the peduncle 
noticeably smaller than the body of the tumor. In the majority of cases 
I have found more than one exostosis in the auditory canal. If at first the 
growths are more or less separate and distinct, at a later stage they will be 
found to merge so completely the one into the other that a mere undulat- 
ing surface is presented to the eye of the observer. 

The bony character of the tumor is easily ascertained by means of the 
probe, or, better yet, by means of the paracentesis needle, or the curved, 
sharp-pointed bistoury. As a rule the surface of these exostoses is very 
slightly sensitive, and the sharp point of a knife is felt even less than the 
pressure of the comparatively broad end of a probe. The skin covering 
them is exceedingly thin. 

There are only two conditions, it seems to me, which justify the sur- 
geon in recommending operative interference with these bony tumors. 
For instance, if there is marked or total deafness in one ear, and the growth 
of an exostosis in the other auditory canal shuts it up and deprives the in- 
dividual of the use of his only available ear, operative interference would, 
it seems to me, be perfectly justifiable and proper. It should first be 
clearly established, however, that a useful degree of hearing existed in the 
ear before the canal became entirely closed by the bony growth. Again, 
if a chronic purulent inflammation of the middle ear is associated with ex- 
ostoses, or with a diffuse hyperostosis, of the osseous auditory canal, and 
if, through the gradual growth of these masses, the canal becomes so nar- 
row that the pus can no longer escape with sufficient freedom, it is clear 
that the only remaining natural outlet for the pus is through the Eustachian 
tube. This channel, however, is very often so narrow that comparatively 
little pus can escape through it. Stagnation follows, and yet pus continues 
to form in this closed cavity. Under such circumstances the indications 
for operative interference are very clear and urgent. It is rare, however, 
that either of the conditions described above occurs. I have never seen a 
case in which operative interference seemed to be indicated ; but Dr. J. Orne 
Green, of Boston, reports ' the case of a young man in whose auditory 
canal two exostoses so nearly closed the meatus that the pus secreted in 
the middle ear could no longer escape freely enough, and death soon fol- 
lowed from the meningitis set up by the retention of the pus. Four days 
before the patient's death, Dr. Green was sent for. By means of a hand- 
drill he established a channel, 3 mm. in diameter, through the exostoses. 
With a larger drill he made an opening, behind the ear, into the mastoid 
antrum, and, by means of the syringe, passed a current of warm water 
from the meatus into the middle ear and antrum, and thence out through 

1 Boston Medical and Surgical Journal, April 18, 1878. 



118 DIAGNOSIS AND TREATMENT OF 

the external wound. The operation, however, had been performed too 
late, and the meningitis went on to a fatal termination. In the case re- 
ported by Dr. Mathewson, l a large exostosis almost entirely closed the 
auditory canal, and materially diminished the patient's hearing. Through 
this mass, which proved to be as hard as ivory, Dr. Mathewson estab- 
lished quite a broad channel by means of drills driven by the so-called den- 
tal engine. The operation was completed in less than thirty minutes. To 
judge from this single experience, this form of motive power presents de- 
cided advantages over that supplied by the hand. The drill can be guided 
with at least equal accuracy, and it can be equally well prevented from 
penetrating suddenly to a greater depth than is desired. In cases such as 
that described by Dr. Green, it may be found desirable to establish a coun- 
ter-opening in the mastoid process, so that a stream of water, introduced 
into the meatus, may enter the antrum and then pass out through the ar- 
tificial opening in the mastoid process. The necessity, or lack of necessity, 
for the establishment of this second opening will depend chiefly upon the 
degree of success attained in cleansing the deeper cavities of the ear, 
through the re-established meatus, and also upon the degree to which the 
mastoid process appears to be involved in the inflammation. 



Cancer. 

I can find but one case on record of a primary cancer of the external 
auditory canal, viz., that reported by Kessel. 2 It is quite possible that 
there are other cases in the literature of this subject, but my limited search 
has failed to discover them. The case reported by Delstanche, fils, 3 as one 
of primary cancer of the external auditory meatus, can hardly be accepted 
as a well-established instance of this disease. I have read the account 
carefully, and am by no means satisfied, nor does Delstanche himself seem 
to be, that the disease may not have developed first in the middle ear. 
Furthermore, Kessel's case can scarcely be considered as entirely satisfac- 
tory. Prof, von Biesiadecki gave him, for microscopic examination, 
twenty-two specimens of polypi that had been removed from the ears of 
different individuals. No histories accompanied these specimens, and no 
other data were known to Dr. Kessel beyond the scanty information which 
he could glean from the labels on the bottles that contained the polypi. 
One of these growths, which was labeled as coming from the external audi- 
tory canal, presented to the naked eye all the features of a medium-sized, 

1 Transactions of the First Congress of the International Otological Society. New- 
York, 1877. 

2 Ueber Ohrpolypen. Arch. f. Ohrenh. Bd. IV., S..184. 

3 Archiv fur Ohrenheilkunde, Bd. XV., S. 21. 



DISEASES OF THE EAR. 119 

knobbed wart. A microscopic examination showed it to be provided with 
hairs, and with sebaceous and ceruminous glands. It therefore, in all 
probability, grew from some portion of the outer half of the meatus. Its 
outer surface was composed of a thick layer of epidermis cells which sent 
prolongations of epithelium deep into the substance of the wart. The pres- 
ence of numerous balls of concentrically arranged epithelial cells and of 
nests of these elements, seemed to Dr. Kessel to establish the cancerous 
nature (epithelioma) of the growth beyond a shadow of a doubt. Such a 
conclusion, however, does not appear to me to be warranted by the facts. 
The minute anatomy of a perfectly benign wart is so like that of the malig- 
nant epithelioma, that without other data (the history of the case, the con- 
dition of the neighboring glands, etc.), one would hardly be justified in ex- 
pressing so positive an opinion. 

Even secondary cancers of the auditory canal are by no means common. 
Of the two cases which have come under my observation, one was preceded 
by a cancer of the middle ear, the other by one that originated in the 
glands of the neck behind and just below the ear. The former case will 
be narrated in detail in the chapter on diseases of the middle ear. The 
facts of interest in the latter case are as follows : The patient, a female, 
thirty years of age, and in rather poor general condition, was seen for the 
first time on the 3d of June, 1872. She stated that nine years previously 
a hard swelling showed itself on the left side of the neck, close behind the 
ear. It came without pain, and gradually increased in size until, at the 
end of five years, it had reached the dimensions of a large egg. It was then 
removed by Dr. Thomas M. Markoe, of this city, who found it to be a cystic 
tumor. The wound healed promptly, and for a period of about three years 
she remained free from any evidence of a return of the growth. Then, 
after the birth of her last child, the parts around the ear became swollen 
and painful. At the end of two weeks the swelling gradually subsided, 
without the formation of matter; the pain disappeared, and the patient 
remained free from all symptoms referable to the region of the ear for a 
period of several months. Early in January, 1872, she passed through a 
second attack of acute swelling of the parts around the ear, and again the 
attack passed off without giving rise to the formation of an abscess. Un- 
fortunately, it is not stated in my notes whether complete subsidence of 
the swelling followed both of these attacks, or whether after each a certain 
degree of permanent swelling remained. It is stated, however, that through- 
out both of these attacks no appreciable deafness and no tinnitus or other 
subjective aural sjmiptoms were present. During the following March she 
experienced a third attack, more severe than any previous one. This time 
there were both deafness and tinnitus, and at the end of a few days an 
abundant, and at times bloody, discharge made its appearance in the ex- 
ternal meatus. From that time onward the discharge was constant, and 
the swelling behind and below the ear steadily increased. Early hi May 



120 DIAGNOSIS AND TREATMENT OF 

Dr. James Little, through whose kindness I had an opportunity of examin- 
ing the patient's ear, opened an abscess situated immediately over the left 
mastoid process. By aid of the probe he ascertained the existence of a 
sinus, leading from the cavity of the abscess into the external auditory 
canal. No denuded bone was found. At the time I saw the patient, about 
four weeks later, the opening behind the ear still existed, and pus could 
easily be forced out through it by pressure made upon the skin in the vi- 
cinity. Just in front of the tragus an irregularly shaped hard mass could 
be felt, which extended backward to the mastoid region. The skin was 
freely movable over the mass. The outer orifice of the auditory canal was 
filled with a reddish, mulberry-like fleshy mass, bathed with a thin pinkish 
pus. When manipulated with the probe it bled easily, but yet was quite 
firm in texture. By grasping the body of the tumor beneath the auricle, 
and moving it in different directions, I was able to satisfy myself that the 
fleshy growth in the meatus was simply an outgrowth from it. By means 
of the probe I ascertained that the cartilaginous wall of the meatus had 
been pierced (as already discovered by Dr. Little) at a point situated pos- 
teriorly and below, and not far from its junction with the osseous portion 
of the canal. One of the fibrous gaps in the cartilage (fissure of Santorini) 
had probably been the point through which first the pus of the abscess and 
then the offshoot of the tumor had forced their way. 

No attempt at an operation was made. The tumor steadily increased in 
size, and eventually caused the patient's death. As no notes were kept at 
the time, Dr. Little is now unable to recall any further details of this inter- 
esting case. 

Sarcoma, 

The following case is the only one of its kind that has come under my 
observation. The history is as follows : 

The patient, a strong, healthy girl, fourteen years of age, consulted me 
on the 25th of May, 1880, for an affection of the right ear, of recent date. 
About two weeks previously she noticed a sensation of fulness and per- 
haps very slight pain in the right ear. This w r as the first intimation that 
she received that her ear was not perfectly sound in all respects. She had 
never previously experienced either pain, discharge, deafness, or any other 
symptom referable to the ear. In the course of a few days a slight dis- 
charge was discovered at the outer orifice, and as the sensation of fulness 
still persisted, the family physician, Dr. A. A. Smith, was called in to see 
the child. On examination with the speculum and reflected light he dis- 
covered that the canal was blocked near the outer orifice, by a rather solid 
fleshy mass, which bled quite freely when he removed a part of it with the 
snare. Being convinced that the case was not one of ordinary polypus of 
the ear, Dr. S. referred the patient to me for further treatment. The tu- 



DISEASES OE THE EAE. 121 

inor at this time extended outward almost if not quite to the plane of the 
outer orifice of the auditory canal. It presented a smooth, but slightly 
uneven surface, felt very firm when pressed upon with the probe, was not 
at all sensitive, and seemed to spring by a very broad base from the upper 
and posterior wall of the osseous portion of the auditory canal. The cer- 
vical glands were not enlarged. The left ear was perfectly healthy. Twice 
in succession I surrounded the mass with a loop of No. 37 malleable steel 
wire, but both times the wire broke when I attempted to make it do the 
work of cutting through the tissues of the tumor. I then employed a 
blunt-pointed, curved (flatwise) bistoury, and endeavored to cut away the 
growth close to its base. The cutting edge of the knife, however, encoun- 
tered bony resistance, and I was obliged, for the moment, to remain satis- 
fied with the removal of two fragments, both together equal perhaps to 
one-third of the entire tumor. Moderately abundant bleeding followed 
this operative interference, but it ceased in the course of a few minutes. 
Exploration with the probe failed to discover any central channel or sinus, 
such as is found in those very similar tumors of the auditory canal which 
depend upon a limited area of carious bone. As soon as the bleeding had 
ceased, the patient noticed that her hearing was as perfect as it had ever 
been. The fragments removed were placed at once in alcohol (90$), and 
were then entrusted to Dr. Wilham H. Welch for examination. His report 
reads as follows: "The larger specimen consists, for the most part, of 
closely compacted, small, round cells, between which is an ill-defined base- 
ment substance or stroma, constituting a reticulum when the cells are 
shaken out. There are also some larger, endothelial-like cells scattered ir- 
regularly among the round cells. The smaller fragment consists more of 
spindle-shaped cells, with a more distinctly fibrous stroma. The growth is 
rich in vessels, whose walls are embryonic, being composed simply of an en- 
dothelial lining and the surrounding tissue. In some parts of the fragment 
the epidermis is preserved. From the microscopical appearances the speci- 
men is probably to be regarded as round-celled sarcoma, but the possibil- 
ity of its being granulation- tissue cannot be wholly excluded." 

On the 26th of May I succeeded, by means of as strong a wire as I 
could pass through Blake's double-mouthed canula, in removing another 
portion of the growth. This, too, was submitted to Dr. Welch for exami- 
nation, with the following results : " The specimen presents in some places 
the same structure as that which characterized the first fragment ; but, in 
addition, it presents certain points of interest. The central part of the 
specimen is hard, and, under the microscope, is found to consist of osseous 
tissue, with wide medullary spaces in which the tissue is rich in cells and 
fibrillated. The rest of the specimen is composed of a tissue containing 
numerous round and some irregular cells. Near to the bone the cells are 
less numerous, more irregular in shape, and have between them a homo- 
geneous, glistening basement substance containing some elastic fibres. 



122 DIAGNOSIS AND TREATMENT OF 

Peripherally tlie cells are more numerous and the intercellular substance 
less glistening and more fibrillated. There are places where the tissue is 
of an osteoid character ; that is, the cells, with fine processes, are inclosed 
in spaces in a homogeneous, bony-looking matrix. These seem to repre- 
sent transition-stages between the sarcomatous tissue and the osteoid tis- 
sue on the one hand, and the osteoid and osseous tissue on the other. 
There are no cells which can be positively claimed as cartilage cells. The 
tumor seems to be an ossifying sarcoma (osteo-sarcoma), taking its origin, 
most probably, from the periosteum." 

The patient was then examined by Drs. Eobert F. Weir and D. B. St. John 
Roosa, separately — both of them experts in diseases of the ear. They both 
agreed that the tumor was not an ordinary connective-tissue growth, and 
favored an early operation for the purpose of extirpating it as thoroughly as 
possible. They thought it advisable, however, that a microscopic examina- 
tion should first be made by another expert ; and accordingly I removed 
(June 7th) another moderately large fragment and submitted it to Dr. 
Francis Delafield. His report, which was made on the 9th of June, fully 
confirms that previously made by Dr. Welch. It reads as follows : " The 
specimen is a small, rounded mass, about the size of half a pea. It was 
removed from the wound left by a previous operation. It is evident that 
the specimen consists of a portion of new-growth situated at the edge of 
the wound. Part of the specimen is covered by a layer of epithelium, and 
beneath the epithelium is connective tissue with an excess of cells and 
mucous tissue. The portions of the specimen not covered by epithelium 
are composed of connective tissue infiltrated with round cells — granulation- 
tissue. Part of the specimen, therefore, represents a new-growth — part 
granulation-tissue from a wound. If we compare this specimen with those 
already examined by Dr. Welch, it is evident that the tumor is one of those 
composite growths which sometimes grow from the periosteum. It is com- 
posed of connective tissue, mucous tissue, bone, and sarcomatous tissue. 
The prognosis of such a tumor is bad, but not very bad. If the growth 
can be completely removed, and if the bone is not involved, there may be 
no recurrence." 

In this connection I should state that, during the short period of ten 
days that elapsed between the two partial operations, the tumor had again 
fully reached its former size, but not its former degree of hardness. The 
fragment submitted to Dr. Delafield represented largely this fresh growth. 

On the 10th of June the patient was brought under the influence of an 
anaesthetic (sulphuric ether), and by means of suitable knives (blunt-pointed 
and curved flatwise) and a sharp-edged steel scoop I removed the entire tu- 
mor, together with a zone of seemingly healthy skin surrounding its base 
on all sides. The growth apparently sprang from the periosteum, as the 
underlying bone felt smooth and hard. A small nucleus of osteoid tissue 
was found in the centre of the growth. The bleeding was trivial in charac- 



DISEASES OF THE EAR. 123 

ter. The denuded bone was carefully scraped, and, in addition, a solution 
of chloride of zinc (forty grains to the ounce of water) was painted thorough- 
ly over all the exposed surfaces. Dr. A. A. Smith and Dr. Eobert F. Weir 
assisted me in the operation. 

For about three hours after the operation the patient experienced a 
moderate degree of pain in the ear. After that she fell asleep and had a 
good night's rest. On the folio wiug morning she said that the ear felt 
perfectly natural. I examined the canal and found the parts covered with 
healthy pus and moderately swollen. The deeper part of the meatus and 
the membrana tympani appeared to be perfectly natural. The watch waa 
heard at a distance of nearly four feet. 

On the 19th of June the patient went with her mother to Newport, 
E. L, and placed herself under Dr. Rankin's care. The treatment consisted 
in daily cleansings followed each time by an application of powdered 
iodoform to the exposed surface of the wound. At the time of her depart- 
ure from this city only a small depressed ulcer remained ; and about the 
28th of June Dr. Rankin reported that this had healed and that no further 
treatment was required. On the 7th of July I had an opportunity of ex- 
amining the ear. A slight excavation alone remained to indicate the spot 
from which the growth had been removed. At the very centre of the 
depression a small dry scab was still visible, but everywhere else the skin 
was pale, smooth, and perfectly natural in appearance. Up to the present 
time (October 1st) no indications of a recurrence of the growth have been 
discovered. 

A careful inquiry into the family history revealed no instances of can- 
cer or any form of tumor among members of the immediate family. Both 
parents are strong and perfectly healthy. The maternal grandmother, how- 
ever, died of some uterine disease which may have been cancerous in its 
nature. An aunt had a tumor removed from her neck. A grandaunt had 
cancer of the breast. Two second cousins also had cancers. 

I have no comments to add to the foregoing history. The case is cer- 
tainly one of great rarity, and perhaps even unique in the literature of 
aural tumors. 

Cysts. 

I have seen but two instances of what might fairly be designated as a 
primary cyst-like formation in the auditory canaL In one case a small, 
yellow body, about the size of a No. 6 shot, and consisting apparently of 
cheesy or sebaceous material, surrounded by a thin envelope of epidermis, 
projected from the anterior and upper wall of the osseous portion of the 
meatus, just beyond the junction of the latter with the cartilaginous por- 
tion. In the second case a somewhat larger cyst, with cheesy or almost 



■■■■■■■■■ 



124 DIAGNOSIS AND TREATMENT. 

chalky contents, and slightly constricted at its base, sprang from a point 
on the upper Weill of the meatus not more than one or two millimetres dis- 
tant from the upper limit of the drum-membrane. It was slightly sensi- 
tive to pressure made with the end of the probe, and seemed to be quite 
solid, though of course not so solid as an exostosis. As isolated glands 
(ceruminous) are sometimes found in the osseous portion of the auditory 
canal, and especially along the upper wall, I think these cysts with cheesy 
contents should be placed in the same category with the sebaceous cysts 
observed in other parts of the body. Their significance, in the ear, is sim- 
ply that of pathological curiosities. 

In the vicinity of the membrana tympani, cyst-like tumors are occasion- 
ally met with, but they are, I think I may safely say, invariably secondary 
to some affection of the middle ear. In some instances, however, the 
primary disease recedes so completely that the cyst-like formation in the 
meatus gains proportionately in individuality, and may even be taken for 
a tumor of primary development. As the description of these secondary 
cysts belongs more properly under the heading of diseases of the middle 
ear, I will say nothing further on the subject in the present section. 



CHAPTEK V 
METHODS OF EXAMINING THE MIDDLE EAR. 

As the membrana tympani constitutes the outer wall of the tympanic 
cavity, and receives its supply of blood from the same system of vessels, its 
appearance as regards vascularity and degree of swelling may be taken as 
an index of the degree of vascularity and swelling of the concealed parts of 
this cavity. Hence, if, on inspection with reflected light, the drum-mem- 
brane appears to be red and swollen, we may safely assume that the mu- 
cous membrane of the tympanic cavity is in very much the same condition. 
There is, I believe, but one exception to this rule, and that is where a dif- 
fuse inflammation of the osseous portion of the meatus involves the mem- 
brana tympani. The very slight disturbance of the hearing, which has been 
observed in these cases, justifies the belief that the processes of congestion 
and infiltration involve only the dermoid layer, and do not extend much 
beyond these limits. 

In the second place, the physical peculiarities of the drum-membrane 
enable us to draw valuable conclusions with regard to two points : first, the 
degree of patency or permeability of the Eustachian tube ; and second, the 
quantity and also at times the character of the fluid contained within the 
tympanic cavity, in cases of fluid exudation. A perfectly normal condition 
of the tympanic mucous membrane, and a perfect condition of the function 
of hearing are scarcely possible unless the membrana tympani is subjected 
to the same degree of atmospheric pressure on both sides. To maintain 
such a condition of equilibrium between the inner and the outer atmos- 
pheric pressures, Nature has constructed the Eustachian tube — the channel 
of communication between the middle ear and the throat — in such a way 
that the air can readily pass through it, to and from the cavity of the tym- 
panum. If through disease this channel becomes closed, the condition of 
equilibrium ceases to exist, for the air in the middle ear rapidly becomes 
rarefied through absorption, and as a result the greater pressure upon the 
outer surface of the drum-membrane forces it inward beyond the position 
which it occupied when pressure and counter-pressure were exactly equal. 
The degree of patency of the Eustachian tube may therefore be estimated 
with more or less accuracy by a careful inspection of the drum-membrane. 
If, for example, the tube is simply obstructed to a slight degree, the mem- 



126 DIAGNOSIS AND TREATMENT OF 

brana tympani, provided it be of normal thickness and transparency, may 
reveal the fact in several ways. In the first place, the increased pressure 
upon the outer surface of the membrane will be likely to change its shape 
from that of a shallow cone to that of a saucer or segment of a hollow sphere. 
If the eye of the observer could see the drum-membrane in its normal posi- 
tion, and then immediately afterward see it in its slightly sunken condition, 
no difficulty would be experienced in appreciating the difference in appear- 
ance between the two states of the membrane. In actual practice, however, 
no such opportunities for comparing the normal and the sunken conditions 
occur, and we are compelled to depend upon other points as guides in deter- 
mining the question whether the membrane is sunken or not. One of the 
most valuable of these is the degree of distinctness with which we can see 
the outlines of the long process of the anvil. If a drum-membrane is nor- 
mal as regards its textures and its position, we should not be able to see 
the long process of the anvil at all. The mere fact that this little bone can 
be seen is good evidence that the membrane is either sunken or atrophied. 
A still better guide in determining the degree of arching inward of the 
diTim-membrane is the apparent position occupied by the handle of the 
hammer with regard to the circumference of the membrane. If the mem- 
brane is not sunken, the handle of the hammer will appear to be of full 
length and to be situated about midway between the anterior and the pos- 
terior limits of the membrane ; there will also be no noticeable prominence 
of the short process. On the other hand if the membrane is sunken, as a 
whole, to such an extent as to carry the handle of the hammer inward be- 
yond the position which it should properly occupy, the latter will appear to 
be unnaturally short, and to occupy a position nearer to the posterior limit 
•of the drum-membrane, and more nearly parallel with it, than it should. 
The short process and the adjacent posterior fold will also appear to be un- 
usually prominent and well-defined, and the soft membrane immediately 
surrounding the short process (Shrapnell's membrane) may present a hol- 
lowed out or depressed appearance. This apparent foreshortening of the 
handle of the hammer is considered by Politzer to be the best guide to the 
degree of arching inward of the membrana tympani. Finally, the shape 
and situation of the " bright spot " furnish some indication of the degree 
of arching inward of the membrane. "With complete absence of any abnor- 
mal depression, the bright spot should be triangular in shape, and should 
extend from the tip of the handle of the hammer to the circumference of 
the membrane. The moment the latter begins to curve abnormally inward, 
the bright spot at once begins to grow shorter and its outlines to be less 
sharply defined. 

If the drum-membrane is decidedly sunken, the degree of curvature will 
be so great that no person who is in the least familiar with the appearance 
of a normal membrana tympani, could possibly fail to recognize the abnor- 
mal depression. 



DISEASES OF THE EAR. 127 

From these different conditions of the drum-membrane, therefore, it is 
often possible to ascertain quite accurately what is the degree of permea- 
bility of the Eustachian tube. We must always bear in mind the possibility, 
however, that muscular force acting through the tensor tympani muscle, or 
rather the retraction of the tendon belonging to this muscle, by whatever 
cause produced, is competent to give rise to precisely the same arching in- 
ward of the drum-membrane as that due to atmospheric pressure. 

As already stated, we may sometimes learn, from a mere inspection or 
the drum-membrane, that the tympanic cavity contains fluid exudation, and 
that this exudation is thin like serum, or viscid in character, or tinged with 
blood. If the cavity is entirely filled with a thin, colorless exudation, the 
drum-membrane presents at times a dull, greenish hue, at other times a 
more pinkish or purple color, due to the reflection of light from the con- 
gested mucous membrane of the inner wall of the cavity. If the tympanum 
is filled with mucus, the membrane is more apt to present a dull, opaque 
appearance. The presence of blood in the exudation communicates to the 
membrane a more or less decided pinkish or red hue, the depth of the 
color being proportionate to the amount of blood present. If the tympanic 
cavity is only partially filled with fluid, and the drum-membrane still re- 
tains a fail* degree of transparency, it is very often possible to see the upper 
limit of the fluid in the form of a delicate but well-defined curved line, that 
looks very much like a hair stretched across a portion of the membrane. 
If the patient moves his head cautiously backward and forward, it is gen- 
erally possible, especially if the fluid is serous in character, to follow the 
changes which take place, under these circumstances, in the relations of the 
fluid-line to that of some fixed object, like the handle of the hammer. If 
our minds are still in doubt about the existence or non-existence of fluid 
in the middle ear, there are one or two simple devices which may be re- 
sorted to for the purpose of settling the question definitely. Thus, for ex- 
ample, air may be forced into the middle ear, by one of the methods soon 
to be described, and thus bubbles, which are very easily seen through a 
comparatively healthy drum-membrane, may be introduced into the fluid. 
Another plan is to watch the fluid-line while the drum-membrane is made 
to perform to-and-fro movements by means of Siegle's suction apparatus (see 
farther on). Finally, if the observer possesses the requisite skill, and the 
patient is not one of the particularly sensitive sort, an incision may be made 
in the posterior half of the membrane, and an outlet thus be afforded 
through which the fluid — if found to be present — may easily be evacuated. 
Farther on I will state my views with regard to paracentesis of the mem- 
brana tympani as a therapeutic procedure in cases of fluid exudation in the 
tympanum. I mention it here simply as one of the resources at our com- 
mand — and, I believe, a perfectly safe one — for determining beyond all 
doubt whether the middle ear contains free fluid or not. 

The suction apparatus of Siegle, or Siegle's pneumatic speculum, often 



128 DIAGNOSIS AND TREATMENT OF 

supplies us with a convenient means of ascertaining important information 
with regard to the mobility of the hammer, the atrophied or non-atrophied 
condition of the drum-membrane, etc. This instrument consists of a cen- 
tral cylindrical chamber, of either metal or hard rubber, to which is at- 
tached a flexible rubber tube about a foot in length. To one end of the 
chamber, which is a little over three centimetres in diameter, a conical 
speculum is fitted ; the opposite end is closed by a glass window placed at 
such an inclination to the axis of the cylinder, that the rays of light used 
for illuminating the drum-membrane may readily pass through it without 
any portion of them being reflected back to the eye of the observer. The 
free end of the speculum is sheathed with rubber tubing, and may there- 
fore be made to fit air-tight into the auditory canal. "When the instru- 
ment is in actual use, the observer, by holding the free end of the rubber 
tube in his mouth, has it in his power to condense or rarefy the air in the 
auditory canal, and, while doing so, to watch the effects of these proced- 
ures upon the drum-membrane and handle of the hammer. 

A simpler and in certain cases equally effective plan of ascertaining the 
degree of elasticity of the membrana tympani, and the degree of mobility of 
the hammer, is to touch these parts lightly with the end of the slender sil- 
ver probe. Every step of this procedure must of course be made under 
adequate illumination and with the membrana tympani in full view all the 
time. If the physician is not sure of the steadiness of his hand, or if the 
patient is very sensitive, this method of observation, so valuable in skilled 
hands, should not be adopted. 

All the methods of studying the condition of the middle ear which I have 
thus far described, are based upon the direct observation of the drum-mem- 
brane. The remaining methods derive their value chiefly from the facts 
which maybe learned by auscultation combined with the forcible introduc- 
tion of air into the middle ear, by way of the Eustachian tube. There are 
three ways of forcibly introducing air into the middle ear: Valsalva's 
method, Politzer's method, and that by means of the Eustachian catheter. 

Id inflating the middle ear by Valsalva's method the patient closes both 
nostrils by grasping the nose with the thumb and forefinger of one hand, 
shuts his mouth firmly, and then makes a strong expiratory effort. In this 
way he compresses the air in the pharyngeal and nasal cavities to such an 
extent that it seeks an outlet through the Eustachian tubes. If the effort 
is successful the physician, who has previously established a communication 
between his own ear and that of the patient, by means of a flexible auscul- 
tation tube, will hear a slight puff or thud, as the air enters the middle ear 
and distends the drum-membrane. Of the three methods at our command, 
this is altogether the most unsatisfactory, at least for the purposes of aus- 
cultation. Whether the fault lies with me or with the method I am unable 
to say positively ; but it has disappointed me so often that I rarely use it 
now, when I desire to learn by auscultation what is the condition of the 



DISEASES OF THE EAR. 129 

Eustachian tube and tympanic cavity. When I wish to observe the changes 
that take place in the membrana tympani, while air is being forcibly intro- 
duced into the middle ear, I still give the preference to Valsalva's method. 
For this purpose it is undoubtedly more convenient than either of the other 
two methods. For therapeutic purposes, as will be explained farther on, 
Valsalva's method must be placed third on the list ; or, better, yet, it should 
be omitted altogether from the category of therapeutic agents. 

Politzer's method is very little better, for auscultation purposes, than 
that of Valsalva, unless the physician can avail himself of the services of an 
assistant. If he attempts to innate and auscultate at the same time he will 
find the task an extremely difficult one, more so in adult patients than in 
children. In the latter, as a rule, so little force is required to innate the 
middle ears, that one can often perform both acts (auscultation and infla- 
tion) with comparative ease. So far as the method itself is concerned, it is 
in principle essentially the same as that of Valsalva. In both methods, for 
example, the middle ears are inflated by compressing the air that is impris- 
oned in the nasal and naso-pharyngeal cavities to such a degree that it over- 
comes the resistance offered by the walls of the Eustachian tube, and forces 
its way into the tympanum. ' There are two respects, however, in which 
these methods differ from each other very widely. In the first place, Val- 
salva's plan necessitates a degree of venous congestion of the head and neck 
that is directly proportionate to the force used in compressing the air con- 
tained in the naso-pharyngeal space. This fulness of the bio Del-vessels 
must necessarily diminish in a measure the permeability of the Eustachian 
tubes ; it also promotes the very pathological condition which in nine cases 
out of ten leads the patient to consult a physician. In the second place, 
Politzer's method, while it is at least equally efficient with that of Valsalva 
in compressing the air contained in the naso-pharyngeal space, is entirely 
free from the two objections which I have just mentioned. It produces no 
fulness of the blood-vessels, nor does it diminish the permeability of the 
Eustachian tube ; on the contrary, it makes the patient open that channel so 
far as it is possible for him to do so by means of the muscles attached to 
its walls. 

The apparatus which is ordinarily used in carrying out Politzer's method 
of inflation consists of three parts, viz., a rubber bag, provided at one end 
with a hard-rubber nozzle, and of such a size and shape that it can readily 
be grasped with the hand ; a short piece of rubber tubing, of such a small 
calibre that the nozzle of the bag will fit it tightly ; and lastly, either a 
cylindrical or a bulbous nose-piece. So many modifications of this appara- 
tus have been introduced during recent years that one can no longer send 
to an instrument-maker for a Politzer's apparatus, and be at all sure that 
he will receive an instrument bearing a reasonably close resemblance to 

1 Occasionally the air also forces its war through the lachrymal ducts. 
9 



■M^HBHBMi^^ 



130 DIAGNOSIS AND TREATMENT OF 

that wliich Politzer introduced about fifteen years ago. In my judgment, 
Politzer's original instrument, or, at all events, that wliich he was in the 
habit of using in 1869, is more thoroughly practical and efficient than any 
of the later modifications. The bag, which is made of soft black rubber, is 
pear-shaped, and ribbed longitudinally at intervals of about one inch. The 
egg-shaped white-rubber bags, and the flask- shaped green-rubber ones are 
much more difficult to manipulate successfully, especially if the operator's 
hand is rather small. The bag which I have used habitually since the spring 
of 1870 was purchased of Leiter, in Vienna, and is to-day apparently as 
perfect as when it left the maker's shop. A second one, purchased at the 
same time, was injured by being left in an exposed closet during the coldest 
part of the winter. The rubber became hard and brittle, and the manipu- 
lations to which the bag was then subjected caused it to crack open. 

Some of the rubber bags are provided with a small opening protected 
by a valve, which closes the aperture the instant the bag is compressed. 
The advantage claimed for these bags is, that the danger of suction is 
thereby prevented. The truth is, that the suction-power exerted, when 
our grasp upon the bag is relaxed, is simply diminished in degree, but not 
entirely counteracted or rendered null. Personally, I prefer the original 
form of rubber bag, which has no opening except that which is provided at 
the nozzle. To prevent suction, when this form of bag is used, it is simply 
necessary to acquire the habit of never relaxing our grasp upon the bag 
until we have finished wiping the nose-piece with the towel (in Politzer's 
method), or until we have withdrawn the nozzle of the bag from the mouth 
of the catheter (in catheterization of the Eustachian tube). 

With regard to the rubber tubing which connects the nose-piece with 
the nozzle of the bag, I may say that it is not an indifferent matter what 
sort of tubing is used for this purpose. In the first place, it is a very com- 
mon error to use too long a piece. The advantage of a long piece is, that 
the operator, in the act of compressing the bag, can swing his arm freely 
without risk of violently twisting the nose-piece in the patient's nose. This 
advantage, however, is more than offset by the loss of power, which is spent 
upon the elastic walls of the tubing. A piece of black-rubber tubing, four 
or five inches in length, with a calibre of about four millimetres, and walls 
at least a millimetre and one-half in thickness, will be found to answer the 
desired purpose very well. It must be remembered, however, that a bag- 
provided with such a short piece of rubber tubing is more difficult to man- 
age successfully than one with a piece ten or twelve inches long. The arm 
must be kept almost perfectly still, and the muscles of the forearm and hand 
must do the entire work. 

Not the least important part of a good Politzer's apparatus is the nose- 
piece. In adults the slightly curved cylindrical, hard-rubber nose-piece 
will be found entirely satisfactory in the great majority of cases. In chil- 
dren under four or five years of age, in whom the nasal orifice is quite small 



DISEASES OF THE EAR. 



131 



and tender, a nose-piece consisting of a spherical or cone-shaped glass bulb 
will usually be found preferable to the cylindrical one. I have always found 
it a difficult matter to purchase ready made a good hard-rubber cylindrical 
nose-piece. It makes very little difference whether the proper curvature 
has been given to the instrument or not, as by means of heat we can readily 
obtain any curve that we may desire. The chief difficulty lies in the small- 
ness of the calibre given to the rubber cylinder of the desired size exter- 
nally. Thus, for example, I selected, from a large number of nose-pieces 
kept for sale by one of our best instrument-makers, the one having the 
laverest calibre. The measurements were as follows: internal diameter, 
If mm. ; external diameter, 4J mm. The nose-piece of the Politzer's ap- 
paratus which I use habitually gives the following measurements : internal 
diameter, 2J mm. ; external diameter, 3£ mm. A simple comparison of 
these figures will show at once the superiority of the latter nose-piece. It 
occupies less room in the patient's nose and allows a much greater quantity 
of air to be forced into the naso-pharyngeal cavities in a given period of 
time and with a given expenditure of force used by the hand in compress- 
ing the rubber bag. The proportions of the longer and 
shorter arms of the nose-piece, and the degree of curvature 
which it should possess, are correctly given in the accom- 
panying cut (Fig. 11). As already stated, if the instrument 
offered for sale does not possess the proper degree of cur- 
vature, the desired shape can easily be obtained by heating 
the instrument over the flame of a spirit lamp until it be- 
comes perfectly pliable. In his recently published treatise 
on otology ] Politzer states that he is now in the habit of 
using exclusively an elastic nose-piece (as suggested by 
Lowenberg) in the place of the curved hard-rubber one. 
He remarks, however, that a certain degree of practice is 
necessary in using such a nose-piece, as one is very apt, in 
closing the nostrils over the soft-rubber tube, to obliterate 
its calibre entirely. The advantages claimed for this form 
of nose-piece are, that it is pleasanter for the patient (that 
is, less painful than when the hard-rubber one is used) and 
less likely to produce nose-bleed. Furthermore, the ar- 
gument is brought forward that in suspicious cases the patient can, at a 
trifling expense, be provided with his own special nose-piece. I have tried 
this flexible form of nose-piece, but cannot say that I like it. I have also 
tried the plan of slipping a short piece of soft-rubber tubing over the or- 
dinary curved hard-rubber nose-piece, and find it useful in cases where the 
unprotected instrument causes nose-bleed. In the great majority of cases, 



Fig. 14.— Nose- 
piece of Politzer's 
apparatus. (Natu- 
ral size.) 



1 Lehrbuch der Ohrenheilktuide fur praktische Aerzte und Studirende von Dr. 
Adam Politzer. Stuttgart, 1878. 



132 DIAGNOSIS AND TREATMENT OF 

however, I find the curved, cylindrical, hard-rubber nose-piece less trouble- 
some to manage, and more effective, than any other instrument of which I 
have any knowledge. 

Before entering into the details of Politzer's method of inflation, I ought 
to state that this operation of suddenly inflating the middle ears, although 
in the great majority of cases a perfectly safe procedure, should never be 
performed until after the condition of the drum-membrane and middle ear 
has been ascertained by direct inspection with the speculum and reflected 
light. I can recall the case of a gentleman, an army officer, in whose mid- 
dle ear there were bands of adhesions which bound the membrana tympani 
down upon the promontory. I did not at that time appreciate the danger 
of forcibly inflating the middle ear under such circumstances, and conse- 
quently made no special effort to moderate the pressure exerted upon the 
bag. The effect of the inflation was to rupture some small blood-vessel in 
the middle ear and fill the cavity with blood, which speedily must have be- 
come clotted. The patient, who depended chiefly upon that ear for his 
power of hearing, at once noticed that the ear felt full, and that everything 
sounded less distinct than before. He never came to see me afterward, and 
I accidentally heard, about a year later, that the hearing in that ear had not 
returned to its previous degree of acuteness, and that my ill-advised interfer- 
ence was looked upon by the patient as the cause of this aggravation of his 
disability. On more than one occasion I have ruptured a highly atrophied 
drum-membrane or a so-called " cicatricial spot," by employing too great 
force in compressing the rubber bag. I have never known any harm to 
come from such ruptures of an atrophied or cicatricial drum-membrane. 
At the same time the effect of an accident like this upon the mind of the 
patient would be very likely to be of a character prejudicial to the physician 
who happened to be responsible for its occurrence. 

With regard to the different steps of Politzer's method of inflation, very 
few words will suffice to explain the entire procedure. The patient is told 
to take a little water into his mouth, and to hold it there, with closed lips, 
until the physician says, Swallow ! At this signal l he should forthwith swal- 
low the water. The physician, on his part, is to hold the bag in his right hand, 
and then, as soon as the patient has taken the water into his mouth, he is to 
introduce the nose-piece into the patient's left nostril, using, if necessary, 
the left hand to aid him in accomplishing this. When the nose-piece of the 
instrument is in its proper position on the floor of the nasal passage, the 
physician should at once compress the nostrils over the rubber nose-piece, 
and give the patient the signal to swallow. The act of compressing the 
bag and forcing air into the nasal cavities should follow the signal almost 
instantly. 

1 If the patient is very deaf, the operator may use some other signal, such as a nod 
of his head, or a nudge with his knee. 



DISEASES OF THE EAR. 133 

This whole procedure, which seems to be a very simple affair, is found 
by many physicians to be at first quite difficult of execution. It may 
therefore prove useful to some if I mention in detail the difficulties which 
beset the operation. In the first place, it is a common mistake to allow 
the patient to take too large a quantity of water into his mouth. As the 
water is taken merely for the purpose of facilitating the act of swallowing, 
a mere sip is all that is necessary. If a mouthful is taken, the act of infla- 
tion is just as likely to force water out of the patient's mouth, over the 
physician's clothes, as it is to drive air through the Eustachian tube into 
the middle ear. Then again, the accident of " swallowing the wrong way " 
is much more likely to occur when a large than when a small quantity of 
water is taken. 

In the second place, beginners are very apt to delay giving the signal 
to the patient too long a time after the nostrils have been compressed. 
The signal should be given and air should be forced into the nasopharyn- 
geal space as soon as possible after the operator has closed the nasal pas- 
sages ; for it must not be forgotten that, with both nose and mouth closed, 
the patient is unable to breathe, and consequently is rapidly approaching a 
condition of discomfort in which a prompt performance of the act of 
swallowing in response to the physician's signal, is no longer possible. 
Some patients find it very difficult not to open their mouths at the instant 
of performing the act of swallowing ; others, and especially children, do 
it purposely, in order to escape the unpleasant sensation caused by the 
sudden compression of air in the nasal cavities. The whole purpose of 
the act of swallowing, in Politzer's procedure, is to render the naso-pha- 
ryngeal cavity a closed space by interposing the soft palate as an air-tight 
diaphragm between the oral and naso-pharyngeal cavities. There are 
other ways, however, in which the same result may be attained. For in- 
stance, the patient may be told to say "hie" or "hoc," or to distend his 
cheeks, by either of which means the desired shutting off of the naso- 
pharyngeal cavity will be effected just as perfectly as by the act of swallow- 
ing. At the same time I think it will be found that in every-day practice 
the swallowing plan gives greater satisfaction than either of the other two 
methods. 

In the next place, if we wish to spare our patients unnecessary pain or 
the discomfort of a nosebleed, it is necessary that we should introduce the 
nose-piece of Politzer's apparatus with some degree of care. The large 
conical glass nose-piece can scarcely be used in such a clumsy or rough 
manner as to cause either pain or nosebleed ; but the curved, cylindrical, 
hard-rubber instrument is very well adapted to cause both, unless intro- 
duced gently and in one particular way. Thus, for example, in each nasal 
orifice there is but one spot where the instrument can properly be allowed 
to remain while the nostrils are firmly compressed over it, viz., on the floor 
of the canal, as close as possible to the outer limit. In this position, the 



134 DIAGNOSIS AND TREATMENT OF 

instrument, if it has not been pushed in too far, will cause very little dis- 
comfort. If the nose-piece is properly curved, it is an easy matter to avoid 
the danger of pushing it in too far, by always allowing the straight portion 
of the instrument to rest against the patient's upper lip, in the direction of 
a line running from the outer angle of the nasal orifice to the outer angle 
of the mouth. 

Finally, the question remains to be considered, how far we should mod- 
ify the different steps of Politzer's procedure when the patient is a young 
child. I have already alluded to the fact that a spherical or cone-shaped 
glass nose-piece will be found better adapted to young children than the 
curved hard-rubber instrument. The pressure employed in compressing 
the bag must also, as a rule, be decidedly less than that usually employed 
in adults. The device of having the patient swallow a little water at a 
given signal can scarcely be resorted to in children under four years of 
age. In an infant it is simply necessary to adjust the glass bulb to one 
nostril, and then, while the other is kept closed by a finger of the same hand 
that holds the bulb in position, to compress the bag. It makes no difference 
whether the child's mouth is open or shut ; the inflation seems to succeed 
equally well in both cases. In children of three, four, or five years of age, 
it is an easy matter to teach them to distend their cheeks at the moment 
the signal is given (blow !). If pain or a sense of fulness in the ear is com- 
plained of immediately after the inflation, it is a good plan to let the child 
swallow two or three mouthfuls of water, in order to facilitate the escape 
of air that may have become as it were imprisoned in the middle ear. 

The employment of Politzer's method for therapeutic purposes might 
properly be discussed in this connection. For practical reasons, however, 
I think it will be better to take up this subject in connection with the 
individual diseases in the treatment of which this procedure plays an im- 
portant part. 

Of the three methods of inflating the middle ear mentioned at the 
beginning of this section, Valsalva's and Politzer's have been sufficiently 
described, and there remains still to be considered that by means of the 
Eustachian catheter. For purposes of auscultation this method is very 
justly preferred to both the other methods. When the catheter is used, 
the air passes through the Eustachian tube into the middle ear in a con- 
tinuous current of one or two seconds' duration. This steadiness and long- 
duration of the current afford the physician ample opportunity to listen 
deliberately to the character of the sounds which it produces. For pur- 
poses of diagnosis, therefore, this method possesses a decided superiority 
over the other two. 

The Eustachian catheters offered for sale in the surgical-instrument shops 
are made of hard rubber, of German silver, or of coin metal. Those made 
of German silver have nothing to recommend them beside their cheapness. 
A well made hard-rubber catheter is an excellent instrument, ard leaves 



DISEASES OF THE EAE. 



135 



very little to be desired. It is very difficult, however, to find a well-made 
hard- rubber catheter ; the calibre is rarely as large as it should be, or else, 
if the calibre is sufficiently large, the total diameter of the instrument is so 
great that we can use it only in exceptional cases. A good serviceable Eus- 
tachian catheter should have a calibre of about two and one-fourth or two 
and one-half millimetres, and a total diameter of not more than three and 
one-half millimetres. This proportion of calibre to total diameter is 
scarcely attainable in an instrument made of hard rubber. The largest 
rubber catheter that can ordinarily be bought in the shops, measures near- 
ly four and one-half millimetres in its total diameter, while its calibre meas- 
ures only two millimetres. For the majority of patients this instrument is 
too large, and yet its calibre" is barely large enough to allow a current of 
air of the requisite force to reach the orifice of the Eustachian tube. On 
the whole, therefore, the silver catheter, if made of coin metal and properly 
proportioned, will be found to give the greatest satisfaction. I warn my 
readers, however, that very many of the silver catheters sold in the shops 
are even less serviceable than those made of hard rubber. The calibre is 
not one whit larger, in proportion to the total diameter, than that of the 
average rubber catheter ; and when such is the case the latter instrument 
has decided advantages over the former. There is also another 
respect in which the silver instrument may be defective ; the V 
rim of the free end is often so sharp as to cause the patient V ;\ 

pain, either during its passage through the nose, or while it 
lies in the mouth of the Eustachian tube. This defect, how- 
ever, can easily be remedied. 

With regard to the curve which a good Eustachian catheter 
should have, I may say that the one represented in the accom- 
panying cut is that which I have found suited to the great 
majority of adult patients. Some of my colleagues use a 
straighter instrument, and others, one of even greater curva- 
ture ; from which it is proper to draw the conclusion that the 
middle ear may be successfully inflated by variously curved 
catheters. To secure the most effective inflation, however, we 
should give the catheter such a curve that, when it is in posi- 
tion and air is forced through it, the direction of the escaping 
current will be the same as that of the Eustachian tube itself. 
The common error, so far as my observation goes, is to give 
the instrument a curve of too short a radius, which causes a 
large part of the force of the current of air to spend itself upon the upper 
wall of the Eustachian tube. In children from five to about twelve years 
of age, it will be found better to use a catheter that is even less curved than 
that represented in the cut ; or one, at all events, in which the curve begins 
at a point considerably nearer the free end than is the case in this instru- 
ment. 



Fig. 15.— Eus- 
tachian catheter. 
(About one-third 
the natural size. ) 



136 DIAGNOSIS AND TREATMENT OF 

The rubber bag used for inflating the middle ear according to Politzer's 
method answers equally well for inflating this cavity through the Eusta- 
chian catheter. These bags are almost always provided with a rounded or 
somewhat olive-shaped end-piece, which may be screwed on or off at pleas- 
ure. When the catheter is to be used, it is a very common custom to substi- 
tute for this end-piece one that represents accurately a section of a cone, 
and that can therefore be made to fit air-tight into the cone-shaped orifice 
of the Eustachian catheter. I have tried both of these end-pieces, and give 
the preference unhesitatingly to the rounded or olive-shaped one. It fits 
the mouth of the catheter so accurately that the degree of leakage may 
practically be left out of the account. In this respect, therefore, it is essen- 
tially on a par with the cone-shaped end-piece. In all other respects, how- 
ever, it is decidedly superior to the latter instrument. It can be removed 
instantly from the mouth of the catheter without disturbing the latter's po- 
sition in the slightest degree, without causing the patient any of the dis- 
comfort which is very apt to accompany our efforts to disengage the tightly 
fitting conical end-piece, and, finally, without risk of exerting suction-power 
upon the mouth of the Eustachian tube. 

"While I believe that a written or viva voce description of the proper course 
to pursue in introducing the catheter into a patient's Eustachian tube may 
aid a beginner in his efforts to perform this operation successfully, I am 
quite positive that the greater part of the lesson must be learned by actual 
experience. It is of comparatively little use to say : at this point, turn to 
the left ; at that, to the right, and so to direct the beginner's manipulations 
from the commencement to the end of the operation. For the beginning, 
it is true, we can lay down a sharply defined rule, which will hold good 
for all cases ; for the end, also, we can give directions which will secure 
success in certainly the great majority of cases ; for the intermediate 
portion, however, we can simply say : follow the instrument, even if it 
perform a complete revolution in its progress to the naso-pharyngeal 
space. These different steps of the procedure I may briefly describe as 
follows : 

The physician should sit directly facing the patient, and on his right 
hand, within easy reach, should be his rubber bag, auscultation-tube, and 
a bowl or goblet, partially filled with water, and containing five or six 
catheters of different sizes and degrees of curvature. He should have his 
forehead-mirror in position, ready for use, as he may at the very beginning 
find it desirable to examine, under illumination by reflected light, the 
patient's anterior nares. Everything being in readiness, the operator 
should place the fingers of his left hand firmly upon the patient's forehead, 
and, with the end of his thumb, he should elevate as much as possible the 
end of the patient's nose, — the object of the latter procedure being to 
straighten the entrance to the nasal passage and in so far to facilitate the 
introduction of the catheter. This instrument should be held lightly by 



DISEASES OF THE EAR. 



137 



the physician, between the thumb and forefinger of his right hand, and at 
no time should force be used in overcoming any obstacles that may be en- 
countered. Just within the nasal orifice, the floor of the nasal passage 
rises up in the form of a ridge, the inner or deeper side of which is more 
abrupt than the outer one. When the catheter is first introduced into the 
nasal orifice, its outer end should be at a somewhat lower level, though in 
some cases we may begin at once with the instrument in a nearly horizon- 
tal position. To pass it beyond the ridge, and engage it in the lower nasal 
passage, the physician must elevate the ring end of the instrument until it 
occupies a nearly horizontal position. It is at this stage of the operation 
that the beginner is very apt to make a mistake. Instead of passing the 
catheter along the floor of the nasal canal, he slips it over the upper surface 
of the inferior turbinated bone, and, on reaching the naso-pharyngeal space, 
wonders why his efforts to turn the instrument into the mouth of the 
Eustachian tube cause the patient such great distress. A glance at the 
illustrations of this region, in some good treatise on anatomy, will show how 
easy it is to make this mistake. It is only necessary to push the beak of the 
instrument a short distance beyond the summit of the ridge, and we shall find 
it slipping only too easily along the wrong channel. When the catheter has 
been pushed beyond the ridge, and is actually resting upon the inferior tur- 
binated bone, the elevation of the ring end of the instrument will not correct 
the error unless the catheter be withdrawn a certain distance. In the first 
stage of the operation, therefore, it is important to hug the floor of the nasal 
passage with the beak of the catheter, at least until the instrument has passed 
beneath the inferior turbinated bone, and is well engaged in the lower 
channel. As already stated, it is better, frorn this point onward, to let the 
instrument find its own way. By this I mean that if the catheter encoun- 
ters some obstacle, we should abandon the attempt to push it onward in a 
certain fixed manner, — i.e., with the beak always pointing downward and 
backward. — and should rotate the instrument slowly, while keeping up a 
gentle pressure from behind, until we find a position in which it no longer 
encounters opposition, but yields to the pressure which tends to drive it 
farther inward toward the naso-pharynx. As we wish the instrument, on 
first reaching the cavity, to he with its beak turned directly downward, we 
should begin at once, after passing the obstacle referred to, to rotate the 
catheter back toward the desired position. If we fail in our efforts to over- 
come the obstacle encountered, we must either resort to an instrument of 
smaller diameter, or try to reach the Eustachian tube by way of the nasal 
passage of the opposite side. The latter course will usually be found the 
preferable one. When the catheter is in the naso-pharyngeal space, with its 
beak turned directly downward, we should first make sure of our bearings 
by pushing the instrument onward until we feel the resistance offered by the 
posterior pharyngeal wall. When the catheter is in this position, we know 
that if we rotate it far enough we shall carry the beak into what is known as 



138 DIAGNOSIS AND TREATMENT OF 

Rosenmtiller s fossa, a slight depression located just behind the mouth of 
the Eustachian tube. Hence, if we wish to introduce the instrument into 
the latter cavity, we must draw it out a distance of two- or three-eighths of 
an inch, and then rotate it through an arc of about one hundred and thirty- 
five degrees (or until a line drawn through the plane of the ring attached 
to the catheter shall pass through the outer angle of the patient's eye). If 
we rotate the beak of the catheter first into Rosenmtlller's fossa, and then 
draw it out a short distance, we can often feel the end of the instrument 
pass over the rounded eminence which constitutes the inner lip of the 
mouth of the Eustachian tube. As the distance of the tubal orifice from 
the posterior pharyngeal wall varies in different individuals, the method 
last described, of guiding our movements by aid of the sense of touch, 
rather than by rough estimates of distance, is the one to which most 
aurists, I think, give the preference. In some individuals the landmark 
which I have just described is so feebly developed, or the surrounding- 
parts are so swollen, that the operator feels doubtful whether he has 
reached the mouth of the tube or not. In such cases the Giampetro- 
Lowenberg method will be found useful. According to this method, the 
catheter is to be rotated toward the Eustachian tube of the opposite side, 
and when its beak occupies a horizontal position, as indicated by the 
metal ring, the instrument is to be drawn out until the resistance of the 
posterior edge of the septum is encountered. The catheter is then to be 
rotated in the opposite direction, through an arc of at least one hundred 
and eighty degrees, into the mouth of the Eustachian tube which it is 
desired to reach. In all three methods, but especially in the one last de- 
scribed, the physician would do well to grasp the body of the catheter with 
the thumb and forefinger of the left hand before he performs the act of 
rotation with his right hand. In any event he will have to grasp it in this 
manner after the instrument finally reaches its proper position, as the right 
hand will be required for other purposes. The support thus afforded to 
the catheter is a very firm one, as the last three fingers of the left hand 
find a strong resting-place on the bridge of the patient's nose, or on the 
lower part of his forehead. So long as the operator's fingers press firmly 
against the patient's skull, he need have very little fear of the disturbing 
influence of a sudden motion of his head upon the position of the catheter. 
When the physician believes that the beak of the instrument is lying in 
the mouth of the Eustachian tube, he should give the patient one end of 
the auscultation tube to place in the meatus of the corresponding ear, and 
should fix the other end tightly in his own auditory canal, preferably the 
left one. 1 With his right hand he should then grasp the rubber bag, and 

1 If the presence of the instrument in the nasopharyngeal space causes the patient 
great discomfort, and especially if the act of swallowing is accompanied by pain, the 
physician may safely assume that the beak of the catheter is not lying in the mouth 
of the tube. 



DISEASES OF THE EAE. 



139 



apply the hard-rubber nozzle of the instrument to the mouth of the Eusta- 
chian catheter. If the latter instrument is in the right position, and the 
Eustachian tube is not unnaturally contracted, he will hear the air streaming 
as it were into his own ear. If the catheter, however, occupies a wrong 
position, he will probably still hear the air streaming out of the end of the 
instrument, but it will no longer seem to be escaping into his own ear ; 
the sound will appear to be more distant and less distinct. 

In withdrawing the catheter from the nasal cavities, no special precau- 
tions are necessary. The instrument is first to be rotated back to its original 
position, with the beak pointing downward, and then it is to be drawn out 
gently from the nose. 

So far as the operation of crossing over from one nasal passage to the 
Eustachian tube of the opposite side is concerned, very little need be said 
in addition to the preceding account. On the whole, I think the operation 
is somewhat easier to perform than the ordinary mode of reaching the tube. 
It is simply necessary to use a catheter with a curve of slightly greater 
length, in correspondence with the greater distance of the tubal orifice from 
the nasal passage through which the instrument is passed. In all other re- 
spects the precautions to be taken are precisely the same as those which 
have been recommended for the more direct operation. 

In former years I experimented with catheters having a double curve, 
and thought at the time that in certain cases they enabled me to accom- 
plish that which I had failed to do with the ordinary single-curved instru- 
ments. During the past three or four years, however, I have used only the 
latter variety of catheters, and do not remember to have felt the want of 
the others a single time. Those interested in the subject will find a full 
description of these double-curved catheters, by Dr. Henry D. Noyes, of 
this city, in the Transactions of the American Otological Society for 1870. 
In the volume for 1872 a description will also be found of the so-called 
" faucial catheter," an instrument devised by Dr. Oren D. Pomeroy, of this 
city. I have had no personal experience with the use of this instrument, 
and must confess that I am prejudiced, on a priori grounds, against its em- 
ployment. 

Besides the methods which I have already mentioned, there are other ways 
of ascertaining the condition of the pharyngeal end of the Eustachian tube. 
Thus, for example, in a few cases it is possible, by means of a Gruber's 
speculum introduced as far as possible into the nasal passage, and reflected 
light, to obtain a fair view of the mouth of the Eustachian tube. The mirror, 
however, must not be used in the manner which I have recommended (p. 
34) for examinations of the ear ; success can only be obtained when the 
eye of the observer is placed at the central aperture. This direct method 
of observation has been still further perfected by the invention of what are 
known as Zaufal's specula, which may be carried in even to the very entrance 



140 DIAGNOSIS AND TREATMENT. 

itself of the tube. In many cases a good view of the tubal orifice and 
adjacent parts can be obtained by means of the laryngeal mirror and 
reflected light. Finally, a very good idea of the condition of the naso- 
pharyngeal mucous membrane, and of the relations of the surrounding 
parts to the tubal orifice, may be formed from an exploration of this region 
with the forefinger (by way of the mouth). 



CHAPTER VI. 
DISEASES OF THE MIDDLE EAR.— NON-PURULENT FORMS. 

Preliminary Remarks. 

Very great obstacles stand in the way of him who attempts to make a 
pathologico-anatomical classification of the diseases of the middle ear. In 
the first place, the dividing line between the different diseases are often- 
times more imaginary than real. Thus, for example, an acute inflammation 
of the middle ear may go so far as to cause a perforation to take place in 
the drum-membrane, and pus to flow for a certain length of time through 
this opening and out into the external auditory canal. We classify the 
disease, under these circumstances, as an acute purulent inflammation of 
the middle ear (otitis media purulenta acuta). Or, the attack may be 
equally painful, but owing to the greater toughness of the druni-ineni- 
brane, or to the more open condition of the Eustachian tube, the inflamma- 
tion begins to subside before the pressure exerted by its encaged products 
causes the drum-membrane to rupture. This pathological process in the 
middle ear would be classified by many authors as an acute catarrhal in- 
flammation of the middle ear (otitis media catarrhalis acuta). The anatom- 
ical changes are precisely the same in both cases, and yet, through acci- 
dental influences, the one is associated with a perceptible discharge of pus, 
while the other is not accompanied by such a discharge. The presence or 
absence of the visible discharge is, therefore, the circumstance which shapes 
our decision in classifying these two apparently different processes. It is 
also for the same practical reasons that we speak of diseases of the Eusta- 
chian tube and of the mastoid cavities, both of which are essential portions 
of the middle ear. An inflammation in the Eustachian tube means almost 
invariably an inflammation, at the same time, of the tympanic cavity ; and 
an entirely independent inflammation of the mastoid antrum or adjacent 
cells is certainly a very rare thing, if indeed it ever occurs. A classification 
upon a strictly anatomical basis is therefore scarcely attainable, and we are 
obliged to fall back upon that which is now almost universally employed 
by writers on diseases of the ear, viz., a classification based partly upon 
anatomy, and partly upon symptomatology. In this connection I should 



142 DIAGNOSIS AND TKEATMENT OF 

like to give expression to the hope that the terms " catarrh " and " catar- 
rhal " may at an early day be employed in a fixed and well-defined sense. 
At present, the term " catarrh" is used differently by different writers. In 
the United States it is applied almost invariably to those cases of inflam- 
mation of the middle ear in which the drum-membrane remains intact. 
In Germany the term is generally used in the same sense, though now and 
then we read of a "purulent catarrh." In Great Britain the term appears 
to be used indifferently for both classes of cases. Judged from an etymolo- 
gical standpoint the term catarrh may very justly be considered as includ- 
ing the idea of a discharge. For practical reasons, however, it seems better 
to restrict the use of the term "catarrh" and ''catarrhal" to those cases 
of middle-ear disease which are not accompanied by a perforation of the 
drum-membrane nor by a visible discharge of pus or muco-pus from the 
middle ear. 



Eustachian Tube. 

Simple catarrh. — I have already mentioned the fact that the mucous 
membrane lining the Eustachian tube and middle ear is in reality a contin- 
uation of that which lines the naso-pharyngeal space. A catarrhal inflam- 
mation ! of the latter region does not necessarily imply an extension of the 
disease to the Eustachian tube, but an inflammation of the Eustachian tube 
is scarcely to be thought of except in connection with a naso-pharyngeal 
catarrh. The ordinary "cold in the head," which is the commonest type 
of an acute naso-pharyngeal catarrh, rarely runs its course without involv- 
ing at least a portion of the Eustachian tube. The subjective symptoms in 
this subacute form of Eustachian catarrh are : a sense of tightness or pres- 
sure in the ear of the side affected ; a slight ringing noise ; a sense of ful- 
ness in the ear after blowing one's nose ; crackling noises during this act, 
and also during eating, swallowing, or gaping ; slight diminution in the 
acuteness of hearing ; and, finally, in some cases slight darting pains. The 
appearances presented by the membrana tympani vary according to the 
degree of obstruction which the swelling of the tubal walls offers to the 
ventilation of the middle ear, and also according to the duration of the ob- 
structed state. If the obstruction is slight, the drum-membrane may pre- 
sent a perfectly normal appearance ; if the walls of the tube are decidedly 
swollen, the air in the cavities of the middle ear soon undergoes absorption, 
and the tendency toward the establishment of a vacuum then produces well- 
marked changes in the appearance of the membrana tympani. In the first 



1 The distinguishing characteristics of such a catarrhal inflammation are, increased 
vascularity, increased secretion, and a varying degree of infiltration of the mucous 
membrane. 



DISEASES OF THE EAR. 143 

place, the membrane appears sunken or drawn inward beyond its natural 
position (see p. 126). In addition to this the coloring of the membrane pre- 
sents a deeper hue, which may border either on the purple or on the green, 
according to circumstances which I am unable to define with precision. In 
a general way, however, it may be said that the greenish hue is often an in- 
dication that fluid exudation has already taken place in the tympanic cavity, 
while the purplish or red color simply furnishes evidence of a distended 
condition of the blood-vessels of the mucous membrane. When the changes 
have gone as far as this, we are no longer able to draw a dividing line be- 
tween a Eustachian catarrh and a subacute catarrhal inflammation of the 
middle ear. In fact, the same observer would be likely to use either term 
indifferently, in a series of cases, without being able to give satisfactory rea- 
sons why he used one term in preference to the other. 

So far as the course of the disease,. its treatment, etc., are concerned, I 
think all these questions may be considered to greater practical advantage 
under the section relating to catarrhal inflammation of the middle ear (see 
farther on). 

Other pathological conditions of the Eustachian tube. — "We sometimes see 
cases in which, although other parts of the organ of hearing may be in- 
volved, the condition of the Eustachian tube constitutes the most salient 
feature of the pathological picture presented. For example, the tube may 
be found impervious to air, or it may be so widely patent that the slightest 
condensation or rarefaction of the air in the naso-pharyngeal space causes 
a corresponding outward or inward movement of the drum-membrane. 
Again, paralysis or spasmodic contractions may take place in the muscles 
which separate the inner from the outer wall of the pharyngeal portion of 
the Eustachian tube. Destructive processes may terminate in the binding 
together of these walls at the pharyngeal orifice. Finally, foreign bodies 
may find their way from the nose into the Eustachian tube. To each of 
these processes or conditions I will now devote a little space. 

I have already referred to the slighter degrees of narrowing which char- 
acterize a simple acute or subacute Eustachian catarrh. In this place I 
propose to consider only those cases in which the stenosis is more marked 
and permanent. The diagnosis of this condition is easily made by a sim- 
ple inspection of the membrana tympani with speculum and reflected light. 
If the tube is completely impervious to air, and has been so for a sufficient 
length of time, the picture presented is a very striking one. The drmn- 
membrane will be found lying like a thin, glistening film in close contact 
with the promontory, mouth of the Eustachian tube, anvil and stirrup. A 
deep depression posteriorly marks the vicinity of the entrance to the an- 
trum. The lower end of the long process of the anvil and the head of the 
stirrup appear to project directly into the meatus. In fact, a superficial ob- 
server might easily be led to the conclusion that the membrana tympani 
had been destroyed, and that he was looking directly into the tympanic 



144 DIAGNOSIS AND TREATMENT OF 

cavity. After inflation by Politzers method the picture presented at the 
fundus of the meatus changes completely. The highly atrophied drum- 
membrane appears to be blown out in the form of a tomato ; the depression 
caused by the immovable handle of the hammer corresponding with the 
hilus for the stem of the fruit. Finally, the small whitish prominence of 
the long process of the anvil will be found to have entirely disappeared 
from view. 

Treatment is of very little avail in these cases of extreme atrophy of the 
drum-membrane. The substantia propria having been entirely destroyed, 
the membrane no longer possesses the power of transmitting sonorous im- 
pulses to the handle of the hammer. In fact, the high degree of elasticity 
which such an atrophied membrane possesses renders it a positive obstacle 
to the transmission of such impulses to the labyrinth. Complete extirpa- 
tion of the membrane, under these circumstances, would undoubtedly for 
the moment materially improve the patient's hearing : the sonorous im- 
pulses would produce a more decided effect, if they came in direct contact 
with the foot-plate of the stirrup than if the latter ossicle were enveloped 
in a soft, highly elastic membrane. However, if the drum-membrane, in 
these cases, has ceased to be of value for acoustic purposes, it still retains 
its protective power in almost undiminished degree. For this reason, and 
also for others which I will mention in another place, I am not in favor of 
interfering surgically in these cases. The question then presents itself, 
How much shall we gain — or rather, how much will the patient gain — if 
we succeed in restoring the Eustachian tube to a normal degree of patency ? 
With a highly atrophied membrana tympani, the gain, I imagine, would at 
best be trifling. However this may be, I can only say that my efforts to re- 
store the Eustachian tube to a normal degree of patency, in cases such as 
I have described above, have invariably proved unsuccessful. 

I might state here that a highly atrophied membrana tympani possesses 
very little regenerative power. In one case (a fairly healthy young man, 
twenty-one years of age) I incised such an atrophied membrane on the 
twenty-seventh day of December. The edges of the wound, which was 
fully four millimetres in length, gaped widely apart. On the 30th I found 
the wound still gaping, and not a trace of inflammatory reaction could be 
discovered. On the 13th of January a free opening still existed in the 
drum-membrane. For how long a period it persisted afterward I am un- 
able to say. 

In all, or nearly all, of these cases of prolonged closure of the Eustachi- 
an tube, we can scarcely fail to notice the condition of the naso-pharyngeal 
cavity. Enormously enlarged tonsils, adenoid vegetations, or a more dif- 
fuse form of hypertrophy of the mucous membrane, will almost invariably 
be found to be present. If these conditions reach a high degree of devel- 
opment during the first years of life (from two to four, for example), they 
niay produce not merely a sunken and atrophied condition of the membrana 



DISEASES OF THE EAR. 145 

tympani, as the direct result of the prolonged closure of the Eustachian 
tube, but even, in a few cases, secondary lesions in the labyrinth, which may 
destroy the hearing-power altogether. 

Although in the great majority of cases the obstruction to the entrance 
of air is due to a diffuse swelling of the walls of the tube, in a few cases a 
more localized lesion will be found. Thus, for example, I once had the op- 
portunity, through the kindness of Dr. Goodwillie, of this city, of seeing a 
well-marked instance of closure of the pharyngeal orifice of the Eustachian 
tube by a band of connective tissue, which stretched like a bridge from 
one side of the orifice to the other. As I very rarely employ posterior rhi- 
noscopy as an aid to diagnosis in diseases of the ear, I am unable to state 
how frequently such lesions are encountered. Dr. Goodwillie, however, as- 
sures me that he has seen several instances similar to the one which I have 
just described. In looking through the back numbers of the Archiv far 
Ohrenheilkunde. I find that two similar cases have been reported, one by 
Schwartze ! and one by Lindenbaum. 2 Other instances are also mentioned 
by Schwartze in his recent treatise on the pathological anatomy of the ear.* 
In the same work will be found descriptions of other varieties of tubal 
lesions, with which I have had no personal experience. 

Unnatural patency of the Eustachian tube is rarely encountered in prac- 
tice. In both of the cases which have come under my observation the pa- 
tient did not seem to be conscious that the ear was in any respect peculiar. 
Both patients consulted me for the relief of a slowly-increasing deafness, 
associated, in one case, with a distressing tinnitus. In the first instance I 
found a large, sharply-defined, oval cicatrix occupying the posterior inferior 
quadrant, and encroaching a little upon the superior quadrant. As I 
watched the drum-membrane, through the speculum, and by means of re- 
flected light, I noticed that this cicatricial portion performed well-marked 
to-and-fro movements, which corresponded accurately with the patient's 
expiration and inspiration. When she held her breath, the cicatricial mem- 
brane remained perfectly motionless. Inflation by means of Valsalva's 
method caused the cicatrix to protrude in the form of a well-defined hemi- 
spherical tumor ; but as soon as the pressure was withdrawn, the cicatrix 
instantly returned to the plane of the surrounding membrane, and again 
performed its to-and-fro excursions, synchronously with the respiratory 
movements. In the second case, the entire membrana tympani presented 
a decidedly atrophied condition. The tip of the manubrium mallei was 
lacking. On questioning the patient I ascertained that in childhood she 
had been subject to a discharge from that ear. From these facts — viz., the 
absence of the end of the handle of the hammer, and the existence of otor- 

! Bd. I., S. 214. 

2 Ibidem, S. 295. 

3 Translated by J. Orne Green, M.D. ; Houghton, Osgood & Co., publishers. Bos- 
ton. 1878. 

10 



146 DIAGNOSIS AND TREATMENT OF 

rhcea during childhood — I drew the conclusion that the unusually thin mem- 
brane was not, as I first supposed, an atrophied membrana tympani, but 
represented a newly formed drum-membrane. Whenever the patient per- 
formed the act of swallowing, this cicatricial or newly formed membrane 
performed a distinct to-and-fro excursion. The respiratory movements, 
however, caused no visible excursion of the membrane. It is quite possi- 
ble that, notwithstanding this absence of a respiratory excursion, the Eu- 
stachian tube was just as patent in this as in the first case. The much 
greater area of the cicatricial portion in the latter case would necessitate a 
correspondingly smaller excursion of any one portion of the membrane to 
which I might direct my attention, — an excursion probably too small for 
the naked eye to detect. 

In seeking for a cause for the extraordinary patency of the Eustachian 
tubes in these two cases, we should bear in mind that both of them fur- 
nished unmistakable evidence of a pre-existing destructive inflammation of 
the middle ear. Instances are on record where such an inflammation 
caused the destruction of the lower wall of the osseous portion of the Eu- 
stachian tube, and eventually led to a fatal issue through ulceration of the 
walls of the carotid artery. If, however, the progress of such a destructive 
inflammation should be arrested before the carotid artery became involved, 
and if reparative action should then set in, I can see no good reason why 
an unnaturally patent Eustachian tube should not be the ultimate condi- 
tion left when the ulcerated parts had fully healed. Again, I am not at all 
certain that an unnatural patency of the Eustachian tube may not result 
from a change in the relations of the soft parts which immediately surround 
this canal. Some years ago, while gaping, I suddenly discovered that I 
had unconsciously rendered one Eustachian tube unnaturally patent. I 
succeeded in keeping my jaws in this peculiar position long enough to sat- 
isfy myself that it was a possible thing to maintain the Eustachian tube in 
a perfectly patent condition for a shorter or longer time, according to the 
will of the experimenter. The rushing sound caused by the air as it passed 
to and from the middle ear with each act of respiration, the easily felt to- 
and-fro movement of the drum-membrane, and the cool sensation caused 
by the moving current of air, all furnished unmistakable evidence of the 
existence of an open channel of some size between the naso-pharynx and 
the middle ear. I have often tried since to reproduce this condition, but 
have only succeeded partially. It is not an uncommon thing, however, for 
patients who suffer from chronic Eustachian catarrh, to learn the knack of 
twisting their jaws in such a way as to open, for an instant, the obstructed 
Eustachian tube, and in this manner to obtain relief from the sensation of 
pressure which many of them find so annoying. 1 

1 For additional information on this subject see Vol. I. of the Archiv fur Ohrenheil- 
kunde, pp. 96 and 139 (Reports of Cases by Lucae and Schwartze). 



DISEASES OP THE EAR. 147 

In spasmodic contractions of the muscles of the Eustachian tube, a positive 
diagnosis can scarcely be made without a rhinoscopic examination. At the 
same time, from the history of the case, and from the absence of any visible 
motion of the drum-membrane, we may infer that the peculiar snapping 
noises, which constitute the only appreciable symptom of the affection, 
are due to spasmodic contractions of those muscles which pull the inner 
from the outer wall of the mouth of the tube. I have seen but one well- 
marked instance of this affection. In this case, unfortunately, no contrac- 
tions occurred during the short time spent at my office, and I was there- 
fore unable to make a positive diagnosis. However, from the condition in 
which I found the drum-membrane, and from the account which the patient 
gave of his ailment, very little doubt can be entertained with regard to its 
nature. The patient, an intelligent man about fifty years of age, and in 
apparently good health, gave the following history : About seven years 
previously he consulted a physician for deafness and a sense of fulness in 
the right ear, and the removal of a large mass of impacted cerumen gave 
him decided relief. During the following year or eighteen months he 
remained free from all aural symptoms. Then he began to experience, 
from time to time, noises of a peculiar character, which followed each 
other in quick succession like a series of taps, but never lasted longer 
than a few seconds at a time. He compared the sounds to the pattering 
of rain upon a tin roof. For a period of at least five years he had con- 
tinued to experience these spasmodic noises, but had never before con- 
sulted a physician for the purpose of obtaining relief from his troublesome 
ailment. On examination I found both drum-membranes very nearly nor- 
mal in appearance. The hearing, for the tick of the watch, was reduced to 
about jv. There was no evidence of anything like an active nasopharyn- 
geal catarrh, although the diminution in the hearing power was probably 
to be attributed to the effects produced by this disease during some earlier 
period of its activity. (The patient was not seen again.) 

Cases have been reported in which the snapping noises were associated 
with synchronous, easily recognizable excursions of the drum-membrane. 
From this circumstance two inferences have been drawn : first, that the ex- 
cursions observed were due to spasmodic contractions of the tensor tym- 
pani muscle ; and second, that the noises heard were due to the sudden 
vibrations which these spasmodic contractions of the tensor tympani muscle 
produced in the drum-membrane. The latter inference is at variance with 
certain well-established facts. For example, in inflating the middle ear 
according to Politzer's method, we cause just such a sudden excursion of 
the drum-membrane to take place as that which would follow a spasmodic 
contraction of the tensor tympani muscle ; and yet I do not remember 
ever to have heard, under these circumstances, any noise that could be at- 
tributed solely to the motions of the drum-membrane. A parchment-like 
transformation of this membrane might possibly render its more violent ex- 



148 DIAGNOSIS AND TREATMENT OF 

cursions distinctly audible ; but in the case reported above, and also in the 
few published cases to which I have had access, no such parchment-like 
condition of the membrana tympani existed. In the next place, in 
Schwartze's account of a case x of " spasmodic contractions of the tensor 
tympani muscle " it is distinctly stated that on inspection of the pharynx, 
during the occurrence of these spasmodic contractions, the soft palate was 
seen to rise and fall involuntarily, and synchronously with the noises. In 
this case, therefore, we cannot exclude the possibility that the noises were 
produced by the spasmodic separation of the phaiyngeal lips of the Eusta- 
chian tube, and not by the visible excursions of the drum-membrane. In 
fact, it is not satisfactorily demonstrated in this or in any of the other pub- 
lished cases of which I have any knowledge, that the excursions observed 
in the drum-membrane were really due to contractions of the tensor tym- 
pani muscle. The question naturally suggests itself in this connection, 
Why might not these excursions of the membrana tympani have been 
produced by the alternate rarefaction and condensation of the air in 
the middle ear, which the spasmodic contractions of the tubal muscles 
caused ? The answer might be made that in the published cases of spas- 
modic objective noises of clearly tubal origin, the membrana tympani in- 
variably remained motionless. This evidence seems to me simply to justify 
the conclusion that in these cases the spasmodic contraction of the tubal 
muscles did not suffice — probably by reason of the swollen condition of the 
mucous lining of the tube — to cause any disturbance in the condition of 
atmospheric pressure within the middle ear. If we could readily and safely 
divide the tendon of the tensor tympani muscle, in those cases of this class 
which are accompanied by visible excursions of the drum- membrane, we 
should possess the means of settling this disputed question in every doubt- 
ful case. Without this operation, however, I do not see how we can, with 
any degree of positiveness, pronounce a case to be one of spasmodic con- 
tractions of the tensor tympani muscle. 

A very full discussion of this whole subject will be found in Burnett's 
Treatise on the Ear. 2 

Quite recently Edward Woakes, of London, has published a paper 3 in 
which he expresses the opinion that a loss of power in the palato-tubal mus- 
cles (the levator and the tensor palati mollis) may play an important part 
in diminishing the acuteness of hearing. He describes two classes of 
cases, one with unilateral and the other with bilateral paresis. The lack 
of symmetry in the motions of the soft palate enables one easily to recog- 
nize the latter form of paresis, while the chief characteristic of the bilateral 

1 Archiv fur Ohrenheilkunde, II. Bd., S. 4. 

2 Published by Henry C. Lea, Philadelphia, 1877. 

3 Throat-Deafness associated with Paresis of the Palato-TTibal Muscles, American 
Journal of Otology, Vol. I., No. 4, 1879. 



DISEASES OF THE EAR. 149 

form is a marked absence of sensitiveness on the part of the soft palate and 
uvula. Speaking of the nature of these forms of paralysis, Dr. Woakes 
says that it is certainly not to be referred to a central origin. " On the 
contrary, these cases belong essentially to loss of vaso-motor nerve-power 
affecting one or more ganglia of the sympathetic system." Farther on he 
says : " These vaso-motor pareses are very local in their manifestations, 
and depend entirely on the condition of the nervi vasorum of the nutrient 
arteries of the motor sensory nerves, and not at all on the condition of the 
sensori-motor centres. It is a question of nutrition of the muscular nerves 
themselves, and this depends on the blood-supply, which again is regulated 
by the vaso-motor nerves. These patients are often anaemic and have un- 
dergone mental worry, besides physical wear and tear. Under such circum- 
stances, the nerve-force is readily exhausted, especially that of the sympa- 
thetic system. Some particular ganglion parts with its force more readily 
than the rest. It is like an exhausted galvanic cell ; you must recharge it 
before it will act. But while thus waiting for recharge, the coats of the 
vessels it should control become the play of physical forces, and under the 
influence of the heart's impulse they stretch and are distended with blood. 
This interferes with the nice balance between arterial tension and tissue 
demand which is essential to nutrition, and hence malnutrition results as 
far as the nerve-tissue is concerned, and hence there is defective motor 
function. Mechanical pressure exerted upon the motor iibrillae is an im- 
portant factor in the production of this paresis, and is due to the great 
accession of blood within the nerve-sheath when the nutrient vessels, being 
deprived of their inhibitory control, experience an enormous dilatation of 
their calibre.*' This description of the pathology of paresis of the palato- 
tubal muscles is followed by an account of a case illustrating the bilateral 
form of the disease. From this account it appeal's that in all but two re- 
spects this case is identical with a not uncommon type of catarrhal inflam- 
mation of the middle ear and Eustachian tube. The points of difference 
are these : the previous history of the case certainly justified the assump- 
tion that an element of nerve-exhaustion entered into the etiology of the 
apparently local disease ; and in the second place, inspection of the soft 
palate revealed the fact that a marked loss of power had taken place in its 
component muscles, a loss of power so great " that a strong faradic current 
applied to the palate excited no muscular action, and was scarcely felt by 
the patient." 

Until I had read Dr. Woakes's interesting paper, I was not aware of the 
existence of any form of aural affection in winch paresis of the palato-tubal 
muscles — and probably also of the tensor tympani and stapedius muscles, 
which are supplied by the same nerves — constituted the prominent feature of 
the disease. During the past few months I have taken pains to examine ail 
my cases of subacute catarrhal inflammation of the middle ear, depending 
apparently on a similar state of the naso-pharyngeal mucous membrane, with 



150 DIAGNOSIS AND TREATMENT OF 

special reference to the pathological views which Dr. Woakes has put forward 
in the paper referred to above. Thus far, however, I have failed to discover 
a fairly well-marked instance of deafness of recent date, which appeared to 
me to depend upon paresis of the palato-tubal (and intratympanic) muscles. 
In several of the cases the previous history pointed very plainly to nervous 
exhaustion — by which expression I mean prolonged mental worry and lack 
of rest — as an important factor in the causation of the deafness, but in none 
of these was I able to demonstrate any muscular paresis of the soft palate. 
In two instances I found this organ and the naso-pharyngeal space so lack- 
ing in sensitiveness that I was able to paint the entire region bordering 
upon the tubal orifices with a twenty-grain solution of nitrate of silver in a 
perfectly deliberate manner. This procedure, which ordinarily causes the 
muscles of this region to contract strongly the instant the parts are touched, 
excited no muscular reaction whatever : the soft palate remained perfectly 
motionless and relaxed. On the other hand, when these patients said " ah " 
or " ee," the soft palate rose promptly and symmetrically, showing clearly 
that no very decided degree of muscular paresis existed. 

As these observations extend over a period of only four or five months, 
I should not be warranted in expressing any decided opinion for or against 
the view that paresis of the palato-tubal muscles constitutes an important 
factor in the causation of certain cases of deafness. I have often thought 
that the difficulty sometimes experienced in inflating the middle ears of 
elderly people by Politzer's method, must be largely due to a paretic con- 
dition of the muscles which open the tubes. The correctness of this view 
is rendered probable by the fact that often, in such a case, when air is 
forced into the Eustachian tube by means of the catheter, it is heard to en- 
ter the middle ear through a channel of normal size. The success of the 
inflation in Politzer's method is dependent in great measure upon the co- 
operation of the dilator muscles of the tube ; on the other hand, in inflation 
by means of the catheter, this muscular co-operation is lacking, and the 
degree of success is directly proportionate to the force of the current of 
air driven through the catheter. The degree of force attainable by the 
latter method is much greater than that which can be attained by Politzer's 
method. It is therefore easy to understand how, in these cases of (assumed) 
paresis of the tubal muscles, inflation by Politzer's method fails to over- 
come the inertia of the more or less rigid walls of the tube, and to force 
air into the middle ear ; while by catheterization no difficulty whatever is 
experienced in accomplishing this object. In further justification of this 
view I might mention the fact that post-mortem examinations of the tubal 
muscles have in certain instances revealed the existence of a high degree of 
fatty degeneration. 1 

1 See, for example, a paper on this subject by "Weber, in the Monatsschrift fur 
Ohrenheilkunde, III. 4, April, 1869. 



DISEASES OF THE EAK. 151 

In the matter of treatment, Dr. Woakes lays great stress on the impor- 
tance of administering such remedies as steel, phosphorus, hydrobromic 
acid, and cod-liver oil. "Phosphorus, steel, and hydrobromic acid possess 
a definite relationship to the vessel area innervated by the ganglia whose 
defective action produced the phenomena of paresis described in the for- 
mer part of this paper. Their action is to increase the inhibitory power 
exercised by the ganglia over the vessels from which it had been withdrawn, 
and when this is restored, an involution process as regards the morbid 
effects of its absence at once commences, w T hich speedily ends in the re- 
moval of the symptoms. This appears to be the rationale of the action of 
so-called 'nervine tonics.' The therapeutic effect of the salts of ammonia is 
essentially of this character, and was illustrated in the case of another pa- 
tient in whom palatal paresis of the left side existed to a very marked ex- 
tent, without deafness, but with loud tidal noises in the left ear, and to 
whom I gave five-grain doses of sesquicarbonate of ammonia three times 
daily with the result that all the symptoms disappeared in a fortnight." 
In addition to the internal treatment, Dr. Woakes recommends the employ- 
ment of the induced current, in the following manner : " One pole should 
be applied to the veil of the palate posteriorly, for which purpose the laryn- 
geal electrode is very suitable ; the other, an ordinary sponge-holder, is 
placed outside the neck over the superior cervical ganglion, which is reached 
by making deep pressure behind the angle of the jaw." 



ACUTE AND SUBACUTE INFLAMMATION OF THE MIDDLE EAR. 

General Consideration.'. 

An acute or subacute inflammation of the middle ear may run such a 
variety of courses and may produce such different lesions that, for the sake 
of convenience, at least, if for no other reason, it will be found easier to de- 
scribe these different pathological pictures as so many distinct types of dis- 
ease. Thus, for example, we can make two main subdivisions, the catarrhal 
and the purulent forms Of acute inflammation of the middle ear. The catar- 
rhal form, again, may be subdivided into the following subordinate yet well- 
marked types : simple acute and subacute inflammation (otitis media catar- 
rhalis acuta et subacuta) ; serous or mucous exudation into the middle ear 
(hydrotympanum ; otitis media serosa sive mucosa) ; and hemorrhagic exu- 
dation into the middle ear (hsemotympanum ; otitis media hemorrhagica). 
The second main subdivision, the purulent variety of acute inflammation 
of the middle ear, may also be subdivided into a syphilitic, a tubercular, and 
a simple form ; at the same time it should be stated that it is only in excep- 
tional cases that we can recognize anything distinctly syphilitic or tuber- 



152 DIAGNOSIS AND TREATMENT OF 

cular in the pathological changes that take place in an acute or subacute 
otitis media purulenta. 

The same causes may produce at one time a catarrhal, at another a pu- 
rulent form of inflammation of the middle ear, according to the degree 
of vigor with which they act, and also partly according to the condition of 
the ear, and of the general nutrition of the individual at the time of the 
attack. Among the different causes of an acute inflammation of the middle 
ear the most frequent is undoubtedly a sudden chilling of the surface of 
the body. Next in order come the eruptive fevers, such as scarlet fever, 
measles, and small-pox. Typhoid fever, and perhaps also typhus fever, may 
give rise, occasionally, to an acute affection of the middle ear. A blow or 
a fall on the side of the head may lead to the same result by causing a dias- 
tasis or even a fracture of the bony walls of the tympanum. Direct violence 
to the parts may be followed by acute inflammation. The introduction of 
fluids through the Eustachian tube into the middle ear, either accidentally — 
during ocean-bathing, for example, or during the use of the nasal douche 
or one of its substitutes — or for therapeutic purposes, is very apt to be fol- 
lowed by a severe type of acute inflammation of the middle ear. Several 
years ago I published an account of several cases of acute otitis media, all of 
which were brought on by flooding the nasal cavities by means of the nasal 
douche, the posterior nasal syringe, or the snuffing method. I then gave 
the opinion, in corroboration of that previously expressed by Dr. Boosa, 
that all these procedures, however carefully carried out, were not free 
from, the risk of setting up an acute inflammation of the ear. "While I 
should like to discuss this question more fully, I must rest content at pres- 
ent with the mere statement that my later experience has only served to 
strengthen the opinion expressed at that time. Finally, in children the 
internal administration of quinine sometimes gives rise to an acute or sub- 
acute inflammation of the middle ear. I have seen several such cases, and 
in two of them (from three to five years of age) I was able to study the 
changes in the ear at such short intervals of time that I could no longer 
doubt the direct effect of the quinine upon the degree of fulness of the 
blood-vessels of the tympanum. As each additional dose of the drug was 
administered, the membrana tympani became more and more congested ; 
and by the time 6 grains, in one instance, and 8 in the other, had been taken, 
the child was in evident suffering from pain in the ear. No further doses 
were given, warm applications were made to the ear, and the pain soon sub- 
sided. In all of these cases there already existed, before the quinine was 
administered, a slight tendency to naso-pharyngeal (and probably Eusta- 
chian) catarrh, as shown by the enlarged state of the tonsils and by the pres- 
ence of an excessive amount of ropy mucus behind the soft palate. Hence 
I am not prepared to say that, in a perfectly normal state of the tympanic 
and tubal mucous membrane, quinine is competent to excite an acute inflam- 
mation, but simply that, in young children more particularly, this drug is 



DISEASES OF THE EAR. 153 

capable of fanning a slight and perfectly painless tubal and perhaps tympa- 
nic catarrh into a decidedly acute inflammation of this region. 



General Symptomatology. 

The two main types of acute inflammation of the middle ear, the catar- 
rhal and the purulent, are characterized, up to a certain stage of the dis- 
ease, by the same series of symptoms. It is only when the pressure of the 
fluid exudation within the tympanum causes the membrana tympani to rup- 
ture, that the distinguishing features of the purulent variety manifest them- 
selves. On the other hand, in the catarrhal form, after the inflammation 
has reached its highest degree of activity, the subsequent course of the dis- 
ease is characterized either by a gradual subsidence of all the symptoms, 
or by the development of certain conditions which justify the employment 
of the terms " hydrotympanum " and " hsemotympanum." So far as the 
syphilitic and tubercular varieties are concerned, the symptomatology of 
these will be considered in a separate section. 



Catarrhal Inflammation of the Middle Ear. 

The symptoms which characterize a subacute catarrh of the middle ear 
are precisely the same as those which have already been enumerated under 
the head of Diseases of the Eustachian Tube, viz., diminution in the acute- 
ness of hearing, a sense of fulness in the ear, subjective ringing or singing 
noises, unpleasant resonance of one's own voice in the affected ear, sub- 
jective crackling noises when the nose is blown, and perhaps occasional 
twinges of pain. Any or all of these symptoms may be present in one and 
the same case. 

So far as the pathology of the disease is concerned, in the great major- 
ity of cases the inflammation commences in the naso-pharyngeal space and 
spreads thence to the middle ear through the Eustachian tube. A sub- 
acute Eustachian catarrh, with more or less swelling of the mucous mem- 
brane which lines the middle ear, would therefore represent the mildest 
type of inflammation of this region. The following case will serve as a 
good illustration of such a type of 

Subacute catarrhal inflammation of the middle ear. — The patient, a young 
man twenty-two years of age, was seen, for the first time, at the New 
York Eye and Ear Infirmary, on the seventeenth day of May,. 1871. He 
stated that about three weeks previously he began to experience difficulty 
in hearing, and that it steadily increased up to the time of visiting the 
Infirmary. It was accompanied by a slight ringing noise in the head, but 
there was no pain nor any other symptom sufficiently marked to attract 



■M^^l^^^M^H 



154 DIAGNOSIS AND TREATMENT OF 

his attention. He also stated that during childhood he had been subject 
to frequent earaches. At the time when I saw him he was still able, under 
favorable circumstances, to understand ordinary conversation quite well. 
The hearing distance, as tested by the watch, was : E. ^f ; L. ^f . Both 
external auditory canals were perfectly normal. On the left side the mem- 
branatympani was appreciably sunken, and through it the outlines of the 
long process of the anvil were distinctly visible. Essentially the same con- 
dition of the drum-membrane existed on the right side. The tonsils were 
moderately enlarged, and the entire pharyngeal mucous membrane pre- 
sented an unnaturally red appearance. Inflation by Politzer's method 
caused air to enter the left middle ear, but not the right. A crackling 
sound characterized the entrance of the air into the left tympanum. The 
hearing distance for the watch, on the left side, rose from f| to -^|, as a 
result of the inflation. 

The treatment consisted in mopping out the naso-pharyngeal space 
with a solution of nitrate of silver, of the strength of twenty grains to the 
ounce of water, and in inflations by Politzer's method. At first the catheter 
was used two or three times, on the right side, as a means of inflating the 
middle ear ; but subsequently, as the swelling of the tube subsided, Polit- 
zer's method alone was found to be sufficient. The greater part of the 
time the patient visited the Infirmary only once a week, thus materially de- 
laying his recovery. However, steady improvement took place in the con- 
dition of the parts and in the acuteness of the hearing. On the 1st 
of July, when treatment was discontinued, the hearing distance for the 
watch was : L. ^ ; E. ^. On the 5th of August he reported that no re- 
lapse had occurred, and that he heard as well as ever before. As he had 
been subject to earaches during childhood, it is more than probable that 
his hearing, before the attack described above, was not normal, at least for 
sounds as delicate as the ticking of a watch. 

The absence of pain, in the case just described, is the feature which 
characterizes it as a subacute, in contradistinction from an acute attack of 
inflammation of the middle ear. The comparatively long duration of the 
disease, and the incompleteness of the recovery, so far at least as the hear- 
ing is concerned, justify the assumption that the attack partook of the na- 
ture of an exacerbation of a pre-existing, but very slight naso-pharyngeal, 
Eustachian, and tympanic catarrh, and was not an entirely fresh attack, 
originating in an individual with perfectly normal ears. Had the affection 
been of the latter nature, the restoration of the hearing would have been 
perfect, and the total duration of the attack would have been much shorter. 
Such cases are quite common and I will therefore not stop to narrate an 
instance. 

In a few cases of subacute catarrhal inflammation of the middle ear I 
have observed conditions which lead me to believe that the swelling of the 
mucous membrane may, in certain cases, be greatest at and near the tym- 



DISEASES OF THE EAR. 155 

panic orifice of the Eustachian tube. The most striking feature in these 
cases is the apparently contradictory relation which exists between the 
patency of the tube and the tensely bulging condition of the drum-mem- 
brane. This protrusion outward of the membrane, in the cases referred 
to, was clearly due to the presence of an excessively large volume of air in 
the cavities of the middle ear. In one of them I pricked the bulging mem- 
brane, whereupon it instantly resumed a perfectly natural position. As al- 
ready intimated, no difficulty whatever was experienced in forcing air into 
the middle ear, and it appeared to enter it readily and without rales. A 
swollen condition of the tube at its pharyngeal orifice, or at any point 
along its course, would have interfered materially with the entrance of air 
into the tympanic cavity, and would have caused the drum-membrane to 
occupy a depressed or sunken position rather than a bulging one. The 
presence of a small mass of mucus at the tympanic orifice of the tube, 
where it might perfectly well play the part of a valve, suggested itself as a 
condition that would explain the peculiar phenomena observed. While I 
should not be justified in rejecting this hypothesis unconditionally, I am 
disposed to believe that a swollen condition of the mound-like tympanic 
orifice of the tube is the pathological condition which harmonizes best with 
all the symptoms and conditions observed in these cases. In the first place, 
in the case already referred to, the patient, for a period of nearly two 
weeks, experienced almost constantly a sensation of fulness or pressure 
in the affected ear. The prick made with the myringotome afforded in- 
stant relief, but it lasted only for a few hours. As this peculiar condition 
was associated with a marked naso-pharyngeal catarrh, I limited my treat- 
ment to tri-weekly paintings of this region with a solution of nitrate of 
silver, to counter-irritation over the mastoid process with tincture of iodine, 
and to inflations according to Politzer s method. During the third week 
the improvement was so rapid and so marked that treatment was discon- 
tinued. This experience, it seems to me, tallies with the hypothesis which 
I have put forward rather than with that of the accidental presence of a 
mass of mucus at the tympanic orifice of the tube. Had the latter been the 
true cause, the forcible inflations of air ought to have dislodged the mass at 
a much earlier period. Finally, it seems a little strange that if mucus 
were present I should have failed both by auscultation and by inspection to 
detect its presence in the tube or in the middle ear. 

Closely connected with these uncomplicated cases of subacute catarrhal 
inflammation is another group of complicated cases in which tma subjective 
symptoms and the pathological appearances of the membrana tympani are 
essentially the same as those which characterize the simpler cases. In the 
group referred to, a more or less permanent obstruction of the nasal passages 
constitutes a prominent and perhaps even the chief factor in the production 
of the deafness. So long as the nasal passages are perfectly unobstructed, 
the acts of breathing, gaping, swallowing, etc., all aid in properly ventilat- 



156 DIAGNOSIS AND TREATMENT OF 

ing the middle ear, that is, in restoring that equilibrium between the inter- 
nal and external atmospheric pressures, which is so essential to perfect hear- 
ing. When the nasal passages, however, become obstructed, the acts just 
mentioned produce, at frequent intervals throughout the day, a condition 
of rarefaction in the air of the middle ears. The effect is very nearly the 
same as that produced by obstruction of the Eustachian tube. In all the 
€ases that I have seen, these conditions have been associated together in 
such a manner that I have not been able to distinguish between the effects 
produced by the obstruction in the nasal passages, and those produced by 
the contemporaneous naso-pharyngeal, Eustachian, and middle-ear catarrh. 
I fully believe, however, that it is an important co-operating factor, and 
that permanent benefit can scarcely be attained in these cases so long as 
the nasal obstruction is allowed to remain. 

In the class of cases just described the disease usually shows a ten- 
dency to pursue a chronic course. The jwognosis — so far as the restoration 
of the hearing is concerned — will therefore depend on the degree of damage 
already done by the disease, on our ability to overcome the obstructions in 
the nasal passages, and on various other circumstances. In the main the 
prognosis is not good. In the simpler cases of subacute catarrhal inflam- 
mation, on the other hand, the prognosis is unqualifiedly good. 

Acute catarrhal inflammation of the middle ear. — An acute catarrhal in- 
flammation of the middle ear differs from the subacute form chiefly in the 
fact of its being characterized by pain. Furthermore, in the higher degrees 
the lesions will be found to be more pronounced than in the subacute vari- 
ety. Very many of the " earaches " of young children, from four to ten 
years of age, are due to such an inflammation of the middle ear. The pain 
is very apt to come on during the night or late in the afternoon, while 
during the earlier part of the day the child may be quite free from pain. 
As neither a discharge, deafness, nor any other serious result characterizes 
these earaches, the parents or friends are very apt to draw the conclusion 
that all earaches are equally harmless, and that they may be allowed to run 
on for days or even weeks without any effort being made to ascertain the 
real cause of the pain. I have repeatedly been called to see children who 
had been suffering from pain in the ear for several days, and in whom the 
inflammation of the middle ear and adjacent parts had already assumed 
serious proportions ; and yet the thought of sending for a physician had 
apparently not entered the minds of the parents until after the inflamma- 
tion had approached very near to the limit beyond which surgical interfer- 
ence is not competent to control the disease. I have often, in these cases, 
asked the parents the question, Why have you waited for so long a time 
before sending for a physician ? The majority have replied : " We thought 
it was simply an earache, and that it would pass off of itself." Others have 
said that in .the previous earaches of their children, the physician who had 



DISEASES OF THE EAR. 15f 

been called simply prescribed the application of a hot poultice, or the in- 
stillation of warm sweet oil to which a few drops of laudanum were to be 
added ; and that they naturally drew the inference that nothing further 
could be done in such cases. 

These remarks, I concede, are of the nature of a digression, but I am 
anxious to call the general practitioner's attention to the harmful results 
that may follow such an erroneous belief, and the present opportunity seems 
to be a good one for the purpose. As I have already said, there is a certain 
foundation for the belief that earaches are harmless ; but such a belief could 
scarcely have become so deeply rooted in the public mind, unless physicians 
themselves had in a measure confirmed it. It would seem natural to follow 
up this statement with the remark that in every case of earache, which does 
not yield readily to local applications of heat, a physician should be sent for 
in order that the underlying pathological condition may be ascertained and 
the proper remedy applied. Unfortunately for the public, very few physi- 
cians in the country districts are provided with the proper instruments, or 
possess sufficient technical knowledge, for the satisfactory accomplishment 
of this object. Aside from all these considerations, however, which in a 
few years, it is to be hoped, will cease to apply to practitioners in the 
United States, the rule, as stated, is a good one. Every earache should be 
considered as the beginning of what later may prove to be a fatal disease. 
It should receive early and constant attention at the hands of a physician 
who is able to examine the ear with speculum and reflected light. In 
other words, knowledge should take the place of guesswork in the manage- 
ment of these acute affections of the ear. 

In the milder types of acute catarrhal inflammation of the middle ear,, 
the peripheral and manubrial portions of the drum-membrane, and espe- 
cially the more fleshy parts which form the upper boundary of the mem- 
brane, will be found red and moderately swollen. If the disease has made 
sufficient progress, a crackling sound will probably be heard when air is 
forced into the middle ear. In the course of twenty-four hours, with or 
without treatment, all these threatening manifestations may disappear. In 
the more pronounced types of acute catarrhal inflammation, however, the 
redness and swelling do not remain confined to the peripheral and manu- 
brial portions of the membrana tympani, but involve also the intervening 
portions. An exudation into the middle ear soon follows, and may even be 
so copious as to cause a bulging outward of the drum-membrane, more 
particularly the posterior half. All these changes may develop in the course 
of a single day, or they may not reach the stage last described until after 
the lapse of several days. If the disease, after reaching this stage, ceases 
its activity and gradually subsides, leaving behind, perhaps, an accumula- 
tion of serum or mucus in the tympanum, the diagnosis of an acute otitis 
media catarrhalis may still be retained on our records. But if it goes one 
step farther, the exuded serum or mucus will become purulent in character, 



158 DIAGNOSIS AND TREATMENT OF 

and, with favoring conditions, a perforation will be established in the drum- 
menibrane. From this time forward, until the perforation heals, the picture 
presented will be that of a purulent inflammation of the middle ear. Illus- 
trative cases would scarcely add new light to the description already given of 
an acute otitis media catarrhalis, and I uiay therefore be permitted to omit 
them. There are certain cases, however, of which I should perhaps give 
a single illustration. I refer to a class of cases which, according to the 
definitions given of the two great classes of acute inflammation of the 
middle ear, belong properly to the catarrhal variety. They represent, in 
reality, aborted cases of acute purulent inflammation of the middle ear ; 
that is to say, the lesions are often as grave as they are in the worst forms 
of this variety, and yet, for some unknown reason, pus is apparently not 
formed, and recovery takes place without a perceptible discharge from the 
ear. The following case may serve as an illustration : 

A young girl, six years of age, and in excellent general health, though 
subject more or less to naso-pharyngeal catarrh, was aroused out of her 
sleep one morning in April by a sharp pain in the right ear. Her mother, 
who had acquired some experience in treating the earaches of her other 
.children, at once applied the warm douche and soon relieved the pain. In 
the course of the afternoon of the same day the child began to complain of 
pain in the left ear. An hour or two later I was sent for by the mother. 
On examination I found the left drum-membrane markedly congested 
throughout its entire extent, but not perceptibly bulging. On the right 
side a purplish tumor occupied the position of the membrana tympani. By 
aid of the slender probe I ascertained that an exudation of dark fluid blood 
had taken place between the substantia propria of the drum-membrane and 
its outer dermoid covering. As the child seemed to hear ordinary conver- 
sation perfectly well, and as the right ear was free from pain, I simply ad- 
vised the mother to use the warm douche in the left ear in the same man- 
ner as she had already used it in the right ear. The pain in the left ear 
was relieved by the douche in a very short time. No discharge was observed 
at any time in the right ear, and the membrana tympani soon returned to a 
normal condition. A few inflations according to Politzer's method consti- 
tuted the only treatment. 

In a second very similar case I found a much larger blood-sac, and 
evacuated its contents. According to the account given by the child's 
mother, an oozing of blood from the outer orifice of the auditory canal 
continued for some time after she left the Infirmary. In this case, also, 
the drum-membrane returned to its normal condition without the develop- 
ment of an otorrhcea. The thought suggests itself, Was not the progress 
of the inflammation arrested by this comparatively copious, spontaneous 
local bleeding ? I think it not unlikely that these attacks, which began so 
vigorously, were in each instance materially subdued in acuteness by the 
spontaneous hemorrhage that followed. 



DISEASES OF THE EAR. 159 

With regard to the prognosis, it may be said that in the very great 
majority of instances it is good. Now and then a case proves rebellious 
under treatment, but as a rule perfect recovery follows in the course of two 
or three weeks. 

So far as the diagnosis is concerned, an error is scarcely possible. The 
evidences of inflammation are too plainly marked for a careful observer to 
be easily misled in his interpretation of the conditions presented. The 
questions which suggest themselves to his mind are, first : Is this a sim- 
ple catarrhal inflammation, or is it the beginning of a severe purulent in- 
flammation ? Mere inspection is not sufficient ; the subjective symptoms, 
and especially that of jDain, must be weighed in connection with the condi- 
tion of the drum-membrane. In children, the thermometer may aid us 
materially in arriving at a correct conclusion ; in adults, it is of compara- 
tively little value. The second question is, Is the red and swollen condi- 
tion of the membrana tympani the expression of an inflammation which 
began originally in the middle ear, or is it due to an extension of a diffuse 
inflammation of the canal on to the drum membrane ? This is sometimes 
a difficult question to answer. If an inflammation of the middle ear has 
progressed so far as to involve the inner end of the external auditory canal, 
we may be quite sure of two things : there will be marked diminution of 
the healing, and a history of rather severe pain. On the other hand, the 
insignificance of the pain and the slight impairment of the hearing are 
very striking features in those cases where the inflammation of the auditory 
canal is the primary affection, and that of the drum-membrane merely a 
secondary affair. In exceptional cases, marked pain and decided impair- 
ment of hearing may characterize the type of disease last mentioned. "Under 
such circumstances it may not be possible to arrive at a correct diagnosis 
without further observation of the course which the disease pursues. 

Mucous or serous exudation into the middle ear {liydrotympanuni ; otitis 
media serosa sive mucosa). — The accumulation of a serous or mucous fluid 
in the tympanic cavity may be brought about in two or three different 
ways. In the first place it may be a simple hydrops e vacuo, due to the 
closure of the Eustachian tube, and to the subsequent absorption of the 
air that may have remained in the middle ear. The pressure being, under 
these circumstances, withdrawn from the walls of the blood-vessels of the mid- 
dle ear, they give up their watery contents to a variable extent, according as 
the tendency to a vacuum is greater or less. The fluid found in the middle 
ear in these cases is a thin, yellowish serum, with just enough admixture 
of mucus to render the fluid slightly sticky. An ordinary cold in the head, 
when it involves the Eustachian tube, and practically closes it for a short 
time, may produce this very condition of hydrotympanuni, without even 
robbing the membrana tympani of its transparency. Again, the exuded 
fluid may represent a hypersecretion of the glands with which the tym- 



MM*^^ 



160 DIAGNOSIS AND TREATMENT OF 

panic mucous membrane is provided. Finally, in many cases probably 
both of the factors mentioned co-operate in producing the fluid exu- 
dation. 

In the main the symptomatology of these cases is the same as that of the 
ordinary cases of subacute catarrhal inflammation. There are certain 
symptoms, however, which of themselves are almost sufficient to warrant a 
diagnosis of fluid exudation into the middle ear. One of these is, the sud- 
den change from somewhat poor to good hearing, or the reverse. This 
change is not like that which so often occurs in cases of impacted cerumen, 
where the brief return of the hearing is accompanied by an explosive sound, 
due to the sudden restoration of a communication between the body of air 
lying between the drum-membrane and the ceruminous mass, and that 
which lies outside of the latter ; the hearing either simply becomes clouded, 
or, "in an equally quiet manner, the cloud seems to disappear. These 
changes in the hearing are clearly due to changes in the position occupied 
by the fluid. In a few cases the patient is able to state definitely in what 
positions of the head the hearing seems to be normal. These are* most 
commonly the position with the head thrown far backward (fluid escapes 
into the antrum ?), and that with the head bent far forward. In both of 
these positions the fluid, if not too viscid and if not too copious, will, in 
obedience to the law of gravity, flow away from the oval and round win- 
dows, thus leaving the ossicles and the membrana tympani secundaria free 
to perform their functions properly. 

Another symptom which is peculiar to these cases, is the sensation of 
something moving in the ear. This is of course not felt when the head is 
quiet, but simply when the head is moved rather suddenly. Sometimes 
the patient gives a correct diagnosis of his condition in the very first words 
of his complaint : " I went in bathing, and got some water into my ear ; 
and I am unable to get it out." He imagines, as a matter of course, that 
the water found its way into the ear by way of the external auditory canal ; 
whereas the chilling of the surface of the body, or the accidental entrance 
of salt water into the middle ear byway of the Eustachian tube, has caused 
an exudation of fluid to take place in the tympanum in one of the ways al- 
ready described. Finally, subjective crackling, squeaking, and bubbling 
sounds may be due to the presence of free fluid in the middle ear ; they 
are just as likely, however, to owe their origin to an abnormally moist con- 
dition of the Eustachian tube. Of more decided value is the symptom of 
hearing gurgling sounds in the ear during, the acts of coughing and sneez- 
ing. 

The course of the disease is a very variable one, though in the majority 
of instances the fluid exudation is soon absorbed and the ear returns to a 
normal condition. Among the following cases will be found instances of 
probably all the types of serous exudation into the middle ear which the 
physician is likely to encounter in practice. 



DISEASES OF THE EAK. 161 

Case I. — The patient, a man thirty-five years of age, had a few days pre- 
viously caught a slight cold in the head, and had thenceforth experienced a 
sensation of fulness in the left ear. "When he consulted me on the 13th of 
May, 1879, I found the left drum-membrane slightly congested at the per- 
iphery. Just below the umbo (the lower end of the handle of the hammer) 
a curved line was visible, which stretched from the anterior to the posterior 
periphery of the membrane. In whatever position the patient's head was 
placed, this curved line (with its concave side looking upward) maintained 
its horizontal position, thus showing clearly that it represented the upper 
boundary of a mass of free and rather thin fluid. Under treatment this 
pathological condition disappeared in about two weeks, and the hearing re- 
turned to its normal degree of acuteness. 

Case II. — The patient, a boy eight years of age, had been somewhat hard 
of hearing, as the mother believed, for about one year. At times, she said, 
lie seemed to hear quite well, and then the deafness would return and last 
for a variable period. When I saw the boy at the Infirmary, on the 12th of 
October, 1870, his right membrana tympani presented no features worthy 
of special note in this connection. On the left side, the drum-membrane 
was noticeably sunken, but not congested nor lacking in a fair degree of 
transparency. In the posterior half of the membrane there was a sharply 
denned " fluid line," ranning from the umbo across the intervening space 
to the posterior periphery. Anteriorly, the limits of the fluid could not be 
defined. Moist rides were heard during inflation. " Fluid line " disap- 
peared after inflation. Decided naso-pharyngeal catarrh. Hearing dis- 
tance for the watch before inflation R 2 in., L. 2 in. ; after inflation, E. 21 
in., L. 15 in. Whispered words were heard distinctly a much greater dis- 
tance after inflation than before it. 

The boy visited the Infirmary for treatment twice a week, for a period 
of four weeks. The fluid had by that time disappeared from the left mid- 
dle ear, and the hearing, for the watch, remained steadily at twenty-four 
inches. On the right side, however, no perceptible improvement in the 
hearing had taken place. 

These two cases are placed side by side because the former represents a 
purely fresh attack in a person whose ears had been previously health}*, 
while the latter furnishes a good instance of the development of hydrotym- 
panum in an individual whose ears had been for months affected with 
chronic catarrhal inflammation. Furthermore, they both represent the 
slighter degrees of fluid exudation into the middle ear. 

Case HI. — A gentleman, sixty-nine years of age, but in vigorous health, 
consulted me on the 9th of December, 1876, for a decided loss of hearing 
in his right ear. He first discovered the defect about six weeks previously, 



102 DIAGNOSIS AND TREATMENT OF 

while suffering from a severe cold in the head. On examining the ear I 
found that the membrana tympani was decidedly sunken. Anteriorly a 
"fluid line " ran directly across from the umbo to the anterior periphery of 
the membrane. Posteriorly the uniform dark coloring of the membrane 
showed clearly that the fluid in this region rose to at least the height of the 
upper limit of the membrane. As the long process of the anvil lay almost in 
contact with the membrana tympani, its whitish body stood out in marked 
contrast with the deep slate color of the surroundings. Inflation by 
Politzer's method changed the entire picture. The fluid line, which before 
was visible only in the anterior half of the membrane, now stretched like a 
festoon from periphery to periphery. The long process of the anvil had 
also completely disappeared from view. 

Under treatment this mass of fluid was dissipated — whether wholly by 
absorption, or partly by absorption and partly by dislodgement, I am un- 
able to say — in less than two weeks, and the hearing returned apparently 
to its former standard of acuteness. 

On first thought it may seem rather strange that in the posterior half 
of the cavity of the tympanum (in the case just narrated) the level of the 
fluid should rise at least to the height of the upper boundary of the drum- 
membrane, w T hile in the anterior half the level should correspond with that 
of the umbo or central point of the membrane. This difference, however, 
is simply due to the effects of capillary attraction. The close proximity of 
the long process of the anvil to the posterior half of the membrana tympani 
supplies precisely the conditions which are necessary to develop the effects 
of capillary attraction, that is, to lift the apparent level of the fluid in this 
region to the highest limits of the drum-membrane. 

Case IV. — This patient, a young man twenty-eight years of age, con- 
tracted a bad cold in the head ten days previously, and shortly afterward 
began to experience a sense of fulness in the right ear, and diminished 
acuteness of hearing. When I examined his light ear at the Infirmary, on 
the 2d of November, 1870, I found the drum-membrane of a peculiar, dull 
hue, and almost directly in the centre of the posterior half the perfectly 
round outlines of a bubble of air, perhaps a millimetre and a half in dia- 
meter, were distinctly visible. This bubble seemed to be prevented from 
rising to a higher level by some unseen object — undoubtedly the end of the 
long process of the anvil and the head of the stirrup. The motions of the 
patient's head caused it to move slowly from one position to another, but 
only a very short distance. (No further notes of the case.) 

It is perhaps more common to find several bubbles lying behind the 
drum-membrane. I remember, in one or two instances of hydrotympanum, 
to have seen (after inflation) the cavity of the tympanum apparently filled 



DISEASES OF THE EAK. 163 

from top to bottom with bubbles, which glided over each other like so 
many balls of glass. The first time I saw this phenomenon I was per- 
suaded that I must have overlooked a minute perforation in the mem- 
brana tympani, and that the mass of bubbles lying before me was resting 
against the outer and not the inner surface of the membrane. By employ- 
ing a small mop of cotton, however, I was able speedily to satisfy myself 
that the bubbles were confined within the tympanic cavity. 

Case V. — The patient, a marketman, thirty-one years of age, came to 
the Infirmary on the 4th of February, 1874. He complained of deafness and 
occasional tinnitus, of several months' standing. Recently, he said, he had 
sometimes observed gurgling sounds in the left ear, and had also noticed 
that when he threw his head far backward, he could hear decidedly better 
than when he held it in the natural upright position. I examined the left 
ear and found the membrana tympani appreciably sunken. Instead of a 
delicate, hair-like " fluid line," a rather broad yellow band crossed the lower 
half of the membrane. Atth? umbo this band was caught up like a festoon. 
Below it the color of the drum-meinbrane was like that of slate. Changes 
in the position of the head caused corresponding changes in the position of 
this band. A free vertical incision was made in the posterior half of the 
membrane, and inflation by Politzer's method was resorted to. In this way 
quite a large quantity of fluid was evacuated from the tympanic cavity, — fluid 
which, in no respect that I could discover, differed froni that found in cases 
which are characterized by the presence of the delicate, hair-like, " fluid 
line." The evacuation of the fluid contents of the middle ear increased the 
acuteness of the hearing very noticeably, and three days later, when he re- 
turned to the Infirmary, I found that this gain had increased rather than 
diminished. 

In all the five cases which have just been described, the fluid found in 
the tympanic cavity was almost purely serous in character. So far as my 
experience goes, it is only in comparatively few cases that the exuded fluid 
is found to consist largely or entirely of tough, tenacious mucus. I do not 
know why, in these few cases, mucus should predominate over serum in the 
exuded material, unless it be that in such cases the mucous glands of the 
middle ear are subjected to a higher degree of irritation than is usually the 
case. I have noticed, for example, that a purulent inflammation' of the 
middle ear, with perforation of the membrana tympani, occasionally termin- 
ates in an accumulation of mucus in that cavity ; the perforation apparently 
healing before the mucous membrane of the middle ear has had time to re- 
turn to a fairly healthy state. At the same time a simple catarrhal inflam- 
mation of the middle ear, such as is commonly found to be the cause of the 
accumulation of serum in the tympanic cavity, is often also the cause of an 
accumulation of mucus. Furthermore, in its symptomatology this type of 



■■■■^MM 



164 DIAGNOSIS AND TREATMENT OF 

middle ear disease is essentially the same as the one which we have just 
been considering. It is more apt, perhaps, to run a chronic course than is 
the serous variety of effusion. So far as the diagnosis is concerned, there 
are several features which justify the physician in suspecting that the effu- 
sion is mucous rather than serous in character. In the first place, rales 
are an almost necessary phenomenon in cases of serous accumulation, unless 
the fluid be too scanty in quantity to reach the level of the tubal orifice. 
In cases of an accumulation of mucus, it is perhaps the exception for rales 
to be heard ; in fact the air, forced into the Eustachian tube by inflation, 
does not seem to reach the cavity of the tympanum at all. In the second 
place, the appearance of the drum-membrane in cases of otitis media mucosa 
is usually quite different from that observed in well-marked cases of otitis 
media serosa. It often has a peculiar dead, milky, opaque appearance, 
which, unfortunately, is sometimes also observed in cases of the serous 
variety. Hence, without paracentesis of the membrane, we can scarcely do 
more than entertain a strong suspicion that the case is one of an accumula- 
tion of mucus in the tympanic cavity. After paracentesis has been per- 
formed, and the exuded material has been forced through the perforation 
into the auditory canal, it becomes, of course, an easy matter to make an 
absolute diagnosis. 

As I shall have occasion, in the section relating to treatment, to refer to 
the course which these cases pursue, I may be permitted to omit all farther 
reference to the subject in this place. 

Hemorrhagic exudation into the middle ear. — There are two classes of 
cases to which the expression just employed may be applied with equal jus- 
tice, viz., those cases of acute catarrhal inflammation in which, during the 
first onset of the disease, a hemorrhage occurs from some vessel in the mid- 
dle ear, and those in which a serous fluid, deeply tinged with the coloring' 
matter of the blood, finds its way into the tympanic cavity through other 
than inflammatory causes. Instances of the latter form of disease are very 
rarely met with, and then usually in connection with a depraved state of 
general nutrition (morbus Brightii). I once published l what I believed at 
the time to be a well-marked instance of this form of hemorrhagic exuda- 
tion. It occurred in a person who was affected with oedema of the lower 
extremities and who presented the characteristic facies of Blight's disease. 
When the patient was seen a second time, a few years later, an intratym- 
panic pulsating, vascular growth occupied the position of the former hemor- 
rhagic exudation, and my previous error in diagnosis became at once ap- 
parent. 

In the other form, that is, as an accompaniment of an acute congestion 
of the middle ear, hemorrhagic exudations are by no means common. I 



1 In the Medical Record for October, 1871. 



DISEASES OF THE EAR. 165 

refer, as a matter of course, to well-denned exudations, the red color of 
which is sufficiently pronounced for it to be readily distinguished through 
the mernbrana tympani Serous exudations, slightly tinged with blood, are, 
on the other hand, often seen, and require no special consideration. The 
blood-vessels of the tympanic mucous membrane seem rarely to rupture 
under the strain to which they are subjected in acute congestion of these 
parts. It is far more common for the vessels which he near the dermoid 
surface to break and afford escape to their contents. Occasionally, as a re- 
sult of violence, both accidents may occur ; some of the blood-vessels in 
the tympanic cavity as well as some of those on the outer surface of the 
mernbrana tympani affording escape to their contents. This happened, for 
instance, in the following case : The patient, a carpenter, in robust health, 
drank to excess one night, got into a fight, and was probably struck on the 
head. At all events, he remembered waking up the following morning with 
a loud ringing noise in the head, marked deafness, and blood oozing from 
both ears. Two or three days later I saw him at the Infirmary, and found 
both external auditory canals partially filled with clotted blood. I re- 
moved the clots and exposed the drum-membranes to view. The right one 
was pale and slightly cedematous on its outer surface, but no trace could 
be found of the spot froin which the hemorrhage came. While the outer 
surface of the left druni-niembrane presented the same appearance as that 
of the right, its deeper tone of color was bluish or bluish-black, indicating 
the presence of dark blood in the tympanic cavity. The man unfortunately 
refused to have an incision made in the drum-membrane, and my notes 
furnish no further details with regard to the progress of the case. He prob- 
ably sought relief at some other charitable institution. 

Treatment. 

In discussing the means that may be employed to advantage in the 
treatment of the different forms of acute and subacute catarrhal inflamma- 
tion of the middle ear, I propose to consider first the local and then the 
general measures. 

Local measures. — If we once adopt the belief that all catarrhal or in- 
flammatory affections of the Eustachian tube and middle ear owe their ex- 
istence to, and are promoted by, a similar irritation or inflammation of the 
naso-pharyngeal mucous membrane, our chief efforts will naturally be di- 
rected toward restoring the latter to a healthy condition. It is not my pur- 
pose in the present treatise to mention all the different methods and reme- 
dies which are commonly employed for the accomplishment of this purpose. 
I will limit myself to a description of those which I have found to be suc- 
cessful in attaining the desired end, and to a statement of my reasons why 
I do not like to employ certain others which are recommended by good 
authorities. 



166 DIAGNOSIS AND TREATMENT OF 

For all the different degrees of naso-pharyngeal catarrh I know of no 
more efficient remedy than nitrate of silver. My mode of using it is the 
following : I wrap absorbent cotton around the end of a malleable steel 
cotton-holder, and then bend the armed end of the instrument in the man- 
ner shown in the accompanying cut. In adults this shorter arm of the instru- 
ment should not exceed one inch in length ; in children, it should measure 
from a half to three-fourths of an inch, according to the age of the child. 
To a distance of about three-eighths of an inch from the end the sides of 
the instrument should be slightly roughened, in order that the cotton-wool 
may cling firmly to it. Before dipping the mop into the solution of the 
remedy, the physician should always pass his finger over it, for the purpose 
of ascertaining whether the sharp end of the instrument is thoroughly well 
covered by the cotton. It is scarcely possible to lay down any well-defined 
rule with regard to the proper size of the mop. As a rough estimate, I 




Fig. 16. — Bent cotton-holder, armed with a mop of cotton. 

may say that, at the point of its greatest breadth, it should measure about 
seven or eight millimetres in diameter for adults, and five or six millimetres 
for children. 

The mop once ready, our next step is to saturate it to the proper de- 
gree with the remedial solution. Here again care must be exercised. If 
we dip the entire mop into the solution, and without further ado introduce 
it into the naso-pharyngeal space, we must not be surprised if the patient 
objects to a repetition of the procedure. The mop filled with the remedy 
is precisely like a sponge saturated with water. The moment the naso- 
pharyngeal muscles contract, they squeeze the mop just as a person would 
a sponge, and cause a stream of the silver solution to run down into the 
larynx, or at least very near to its entrance. The symptoms thus caused are 
always extremely unpleasant, and, in a few instances, they may be decidedly 
alarming. On more than one occasion, in former years, I have completely 
demoralized both the patient and the patient's friends by the spasm of the 
glottis which had been provoked by my careless mode of applying the rem- 
edy. To avoid these unpleasant symptoms we either should saturate the en- 
tire mop, and then, by pressure, carefully remove the excess of fluid, or we 
should saturate only one half of the mop, leaving the other half to serve 
the purpose of a receiver into which the excess of fluid, pressed out of the 



DISEASES OF THE EAR. 16" 

moist half of the mop by the naso-pharyngeal muscles, may escape. This 
latter method is the one which I usually employ, and even then I endeavor 
to remove as much of the fluid as I can by pressing the saturated end of 
the mop against the neck of the bottle. 

The steps of this operation of mopping out the naso-pharyngeal cavity 
are the following : The patient should sit directly facing the physician, 
with the source of light on one side of and a little behind him. Holding 
the instrument in his right hand, pressing the patient's tongue down firmly 
with the tongue-depressor, and keeping his pharyngeal cavity well illu- 
minated by means of the forehead-mirror, the physician should pass the 
mop high up behind the soft palate, first toward one Eustachian orifice, and 
then across toward the other. If only one ear is affected, it will often be 
found sufficient to introduce the mop only on that side of the naso-pharyn- 
geal cavity. Sometimes, when the attempt is made to carry the mop across 
from one tubal orifice to the other, quite a decided obstacle is encountered 
in the form of a hemispherical projection of the mucous membrane situ- 
ated exactly in the median line of the posterior pharyngeal wall. If the 
instrument be pulled forward a little, no difficulty will be experienced in 
carrying the mop past the obstacle. In certain patients the mere act of 
depressing the tongue causes them to retch so persistently that all attempts 
to introduce the mop into the naso-pharyngeal cavity by way of the mouth 
have to be abandoned. It is often possible, however, in such cases, to ac- 
complish the desired object by performing the operation with great speed. 
If this plan be adopted, the physician should be careful to protect his per- 
son, lest the contents of the patient's stomach be suddenly showered upon 
him. Finally, by wrapping a towel around the end of the patient's tongue, 
and instructing him how to pull that member well outside of his mouth, 
the physician may be able to reach the naso-pharyngeal cavity without pro- 
ducing the unpleasant results just mentioned. 

In making remedial applications to the naso-pharynx the physician 
must notice particularly whether, and to what extent, the mucous membrane 
of that cavity is covered with mucus. On simple inspection he may very 
easily fail to discover the presence of any appreciable amount of mucus, 
and yet, on introducing his mop, be surprised to find that region well 
coated with a tough, tenacious, dirty-looking material which clings like a 
false membrane to the underlying tissues. It is easy to see how slight must 
be the degree of effectiveness of say a twenty or even a forty-grain solution 
of nitrate of silver when introduced into the naso-pharynx under such 
circumstances. Very little of it, as a matter of course, ever reaches the 
mucous membrane, and consequently little or no benefit results from the 
procedure. It is therefore important to first remove this coating of mucus 
from the naso-pharyngeal cavity, before we undertake to bring our remedies 
to bear upon it. For this purpose I am in the habit of employing simply 



168 DIAGNOSIS AND TREATMENT OF 

dry mops of cotton. A single introduction -usually suffices to bring away 
any free mucus that may be present ; but sometimes I have experienced 
great difficulty in removing the tenacious material, and have even been 
obliged to employ forceps. I have no doubt that Weber's nasal douche, or 
the nasal syringe, might be used to great advantage in freeing the naso- 
pharyngeal cavity from such a tough coating of mucus ; but, as I have al- 
ready stated in an earlier section, my experience justifies me in considering 
this therapeutic procedure by no means a safe one, and I am therefore un- 
willing to recommend it for the purpose named. 

The next questions of importance are, What remedy or remedies are the 
most effective in subduing a naso-pharyngeal catarrh ? and How often should 
they be applied, and in how strong solutions ? My answer to the first ques- 
tion is this ; I rarely employ any other remedy than nitrate of silver. Dur- 
ing the first years of my practice as an aurist I conscientiously and hope- 
fully tried all the different solutions, powders, and sprays of which the nu- 
merous text-books and monographs speak in such favorable terms. As 
time went on, I found my stock of remedies gradually dwindling down until 
only four remained, viz., nitrate of silver, tincture of iodine, tannic acid, 
and alum. In all of these I place some confidence : in the first two I place 
a great deal of confidence, and more particularly in the first one. In young 
children, from four to eight years of age, I begin with a fifteen-grain solu- 
tion of nitrate of silver and soon increase the strength to twenty or twenty- 
five grains to the ounce of distilled water. I first mop out the naso-pharyn- 
geal cavity with the remedy," and then, after preparing a fresh mop, I paint 
the surfaces of the tonsils and the visible portion of the posterior pharyngeal 
wall. If some of the solution trickles down in the larynx, and causes violent 
coughing, or a spasm of the muscles of the glottis, I give the patient quickly 
cold water to drink. On the next day but one, I repeat the application of ni- 
trate of silver, and continue to do so on every alternate day until the naso- 
pharyngeal mucous membrane has returned to a healthy state. In a few 
cases the mucous membrane returns to a perfectly healthy condition, so far 
at least as we can judge by simple ocular inspection ; in the majority of 
cases, however, the catarrhal process simply subsides, under treatment, to 
a minimum degree of activity, — that is, the mucous membrane returns to a 
comparatively normal condition. In healthy children the naso-pharyngeal 
mucous membrane can usually be restored to this comparatively normal 
condition in the course of from two to four or five weeks. 

From a comparison of the results obtained in numerous cases I am dis- 
posed to consider a twenty-grain solution of nitrate of silver as that best 
adapted to the average case of acute or subacute naso-pharyngeal catarrh. 
In deciding, in any given case, whether to increase or to diminish the 
strength of the solution, I am guided by the following considerations : If 
the employment of the twenty-grain solution is followed by a sense of dis- 



DISEASES OF THE EAK. 109 

comfort, and perhaps even by pain, lasting for several hours afterward, I 
employ the next time a weaker solution, say one of fifteen grains to the 
ounce. On the other hand, if the sense of discomfort following the appli- 
cation passes away in the course of half an hour or an hour, we may safely 
assume that only a beneficial effect has been produced. Again, if the secre- 
tion of mucus continues with unabated activity, if the swelling of the parts 
does not diminish, and if their congested hue does not give place to a paler 
color, after four or five applications have been made, I then proceed with- 
out further delay to the employment of a thirty- or even a forty-grain solu- 
tion. In those cases which are characterized by the presence of a tough 
mass of mucus in the naso-pharynx, I have repeatedly failed to obtain a 
satisfactory degree of improvement until I had employed a nearly saturated 
solution of nitrate of silver. By a nearly saturated solution I mean one 
obtained by rubbing the wet mop over the stick of nitrate of silver several 
times in succession. When a strong solution like this is used, it is of course 
doubly important to remove the excess of fluid from the mop. 

I have placed the tincture of iodine second on my list of remedies, not 
that I have good solid reasons for believing it less efficacious than nitrate 
of silver, but simply because patients dislike it so much more than they do 
the latter remedy. For this very reason I have not often employed it, and 
when I have, it has usually been in cases which had not responded well to 
the applications of nitrate of silver. The experience gained from this limited 
use of the remedy justifies me in speaking favorably of it. I have used 
both the simple and the compound tincture, and have not diluted either of 
them. In young children I have never attempted to introduce the remedy 
into the naso-pharyngeal cavity, but have found it serviceable as an applica- 
tion for the swollen mucous membrane of the visible pharynx. 

So far as the naso-pharyngeal cavity is concerned, I have used alum and 
tannic acid in various forms, but never with much satisfaction. Chlor- 
ate of potassa I have used with even less satisfaction. They all seem to 
possess — if I may use such an expression — very little penetrating power. I 
can recall one case, however, in which excellent results were obtained by 
the systematic employment (daily), for a period of three or four weeks, of 
finely powdered burned alum. The patient, a strong, healthy man about 
fifty years of age, and apparently of temperate habits, was suffering from 
a most distressing tinnitus. His entire pharynx was very markedly con- 
gested, and there was a moderate degree of swelling of the parts. He vis- 
ited the Infirmary twice a week, for a period of several weeks, but received 
little or no benefit from the treatment adopted (applications of nitrate of 
silver solutions to the affected mucous membrane, and inflations according 
to Politzer's method). Then, by way of experiment, Dr. Charles Laight, 
my associate in that instilution, proposed to the man to come every day to 
his offfce, and have finely pulverized burned alum blown upon the affected 



170 DIAGNOSIS AND TREATMENT OF 

pharyngeal mucous membrane (not upon that of the naso-pharyngeal cavity). 
The man eagerly consented, and visited the doctor faithfully for a period of 
about four weeks. At each visit, if I remember rightly, two or three infla- 
tions according to Politzer's method were made. It is possible, also, that 
the man was induced to abstain from smoking. No other measures, how- 
ever, were adopted that might have exercised a beneficial influence upon 
the condition of the throat, and secondarily upon that of the ear. At the 
end of the period mentioned I examined the patient's throat, and found it 
practically normal in all respects. The congested appearance had entirely 
disappeared, and the tinnitus was so insignificant that the man paid no at- 
tention to it whatever, and considered himself as cured. In this case the 
beneficial influence exerted by the remedy upon the mucous membrane of the 
pharynx extended to that of the naso-pharynx and middle ear. The excel- 
lent results obtained in this case led me to hope for similar results in other 
cases ; but I must confess that in this I have been disappointed. I cannot 
recall a single instance in which any such brilliant result has been attained 
either by this drug or by nitrate of silver. I have obtained fairly good 
results, however, with powdered burned alum in quite a number of 
cases. 

I ought perhaps to explain in this place why if powdered burned alum 
is an effective remedy in allaying pharyngeal catarrh, I should not also em- 
ploy it as a direct application to the naso-pharyngeal cavity. My reasons 
are these : In the first place, I have tried this plan of treatment and am not 
at all satisfied with the results obtained by it ; and in the second place, the 
patients themselves dislike the remedy, when used in this manner. At first 
I employed the alum in its full strength, and each time the application was 
followed by a most distressing " cold in the head," as the patients described 
it, which lasted for hours. I then diluted the alum with powdered sugar 
of milk, but thereby simply diminished the severity of the unpleasant symp- 
toms. When a finely divided powder is blown into the naso-pharyngeal 
cavity, portions of it undoubtedly find their way into the communicating 
nasal, frontal, and maxillary cavities. To the mucous membrane lining 
these parts such a drug as alum, for instance, is known to be highly irri- 
tating. Hence, in the form of a powder, neither alum nor tannin can 
be employed as a direct means of treating the naso-pharyngeal cavity, 
without causing the patient unnecessary discomfort. This same objec- 
tion applies in a measure to a finely divided spray. The expensiveness, 
however, of the apparatus required for obtaining a good spray prac- 
tically places this mode of treatment out of the reach of the majority of 
practitioners. If used in the form of a solution, both alum and tannin are 
apparently much less efficient than either nitrate of silver or the tincture of 
iodine. 

In a certain proportion of the cases, the methods which I have already 



DISEASES OF THE EAPw. 17 1 

described fail to accomplish the desired purpose, or, if they apparently suc- 
ceed, a relapse soon occurs, and a resumption of treatment becomes neces- 
sary. In these cases the physician would do well to explore the naso- 
pharyngeal cavity with his finger, for the purpose of ascertaining whether 
the obstinate irritation is not kept up by what are termed "adenoid vege- 
tations, " or follicular swellings, of the naso-pharyngeal mucous membrane. 1 



1 For the information of those who may not have read Meyer's classical treatise on 
Adenoid Vegetations in the Naso-pharyngeal Space (Archiv fur Ohrenheilkunde, 187o 
and 1874), I will give here a brief abstract of the more important portions of this 
admirable contribution to otology. 

Out of 175 cases in which adenoid vegetations were discovered in the naso-pharyn- 
geal space, Meyer found that 130, or 74 per cent., were hard of hearing. As the 
mucous membrane of this region passes by direct continuity into that of the Eusta- 
chian tube and middle ear, we can readily understand why, in so large a proportion 
of the cases, the organ of hearing should participate in the naso-pharyngeal inflamma- 
tion. The pathological condition referred to, under the title of "adenoid vegeta- 
tions," consists in the presence of numerous, variously shaped tumors in the naso- 
pharyngeal space. These vary in size from a mere follicular enlargement to a mass 
the size of a cherry-pit, or even a hazel-nut. Sometimes they are pedunculate, at 
other times they are grouped together in a row, like the teeth of a comb. These 
masses are very vascular, and consequently of a bright red color ; they have about the 
same consistency as the parenchyma of the liver, and present either a smooth surface 
or one that is slightly granular. They rarely occur singly ; as a general rule, there 
are as many as from four to eight. The presence of these tumors implies a degree of 
inflammatory irritation in the mucous membrane of this region, which can scarcely 
exist without an inflamed condition also of the Eustachian tubes. But these tumors 
may injure the organ of hearing in a purely mechanical manner. Thus Meyer mentions 
cases where one or two of these tumors, growing from favorable points, attained such 
proportions as to completely block the entrance to the Eustachian tube. 

The microscopic examination of these tumors showed them to be composed chiefly 
of what Meyer terms "adenoid tissue," viz., a network of connective tissue support- 
ing countless lymph corpuscles, or lymphoid cells, as they are sometimes called. Here 
and there, throughout the section, the outlet ducts of acinous glands were also encoun- 
tered. 

The chief symptoms characterizing this affection are the peculiar expression of the 
face, and the defective pronunciation of certain words; both of these phenomena 
being generally associated with more or less deafness. As regards the expression of 
the face, Meyer describes it in the following words : "In well-marked cases the mouth 
is constantly open, and the breathing takes place exclusively through it. There is 
also a lack of tone in the play of the features, and the expression is characterized by a 
certain shade of sadness. After the breathing has taken place for a certain period of 
time exclusively through the mouth, the nose assumes a peculiar sharpness of outline ; 
it looks pinched, and the alse appear to be sunken. If the patient happens to be suf- 
fering at the same time from a chronic nasal catarrh, this peculiar expression of the 
nose will, as a matter of course, not exist." The patient's pronunciation is defective 
in two respects : in the first place, the voice lacks the normal resonance ; and in the 
next, the nasal tones— m, n, ng — are exchanged for others. Thus, for example, the 
patient does not say "Nase," but " Dase " or " Lase." Again, for the word " Zinv 



172 DIAGNOSIS AND TREATMENT OF 

If lie finds this to be the case, lie may safely assume that, by any or all of 
the therapeutic methods which I have described, he will probably fail to per- 
manently relieve the patient of the more active manifestations of his naso- 

mermann," he will say " Zibberbad," and for u Gesang," " Gesagk," and so on. These 
of course illustrate the modifications of pronunciation in a well-marked case. Such 
patients, Meyer says, have also great difficulty in singing high tones. Among other 
symptoms, he mentions the partial or total loss of the sense of smell, habitual head- 
aches, the sensation of a foreign body in the back part of the nose, and the frequent 
escape of blood from the naso-pharyngeal region into the mouth. This last symptom 
he observed in a little over fifteen per cent, of all the cases that came under his ob- 
servation. 

While in this form of disease a positive diagnosis can only be made by physical 
means, — inspection of the naso-pharyngeal cavity by aid of the rhinoscope and reflected 
light, or an examination of these parts with the finger, introduced through the mouth, 
— we can nevertheless expect confidently to find adenoid vegetations in the naso- 
pharynx whenever we encounter the peculiar expression of countenance and the de- 
fective pronunciation described above. In support of this statement, Meyer men- 
tions the fact that he examined 2,000 school children of both sexes in the public 
schools of Copenhagen, for the purpose of ascertaining, simply by looking at their 
faces and hearing them speak, hew many of them were suffering from this affection. 
He found twenty children (1 per cent.) in whom these characteristics were well marked, 
and in each instance he verified the diagnosis by a digital examination. Meyer made 
a similar investigation in England, and found the proportion to be 13 out of 700, or 
nearly two per cent. 

With regard to the question of age, Meyer found that, out of 175 cases, 134, or 76 
per cent. , were between the ages of five and twenty ; the youngest patient was three 
years old, the oldest fifty-nine. In a few instances he found that there was a family 
tendency to this affection. Thus, in three instances, three sisters were affected with 
the disease, and in seven, two sisters. 

As regards the etiology of this disease, Meyer simply states that the same causes 
which co-operate to produce a chronic catarrh of the naso-pharyngeal mucous mem- 
brane also play a chief part in the production of adenoid vegetations. 

So far as his observations extend, Meyer believes that these vegetations usually 
commence to grow in childhood, but remain stationary during youth ; and, if left to 
themselves, they will shrink away and disappear during maturity. Hence, so far as 
they themselves are concerned, these vegetations might be allowed to remain without 
any interference on the part of the surgeon. But when we take into account their 
important relations to the organ of hearing,— not to speak of the unnatural and dis- 
agreeable tone of voice which they produce,— it becomes necessary to get rid of those 
already formed, and to check the further production of new ones. 

The prognosis, as regards the results of treatment, seems to be quite good. Meyer 
states that among a number of cases which remained under observation for a period 
of from two to five years, and in which the vegetations had been thoroughly removed, 
not a single relapse occurred. The prognosis, as regards the hearing, is also quite 
good. Out of 112 cases which had undergone proper treatment, the hearing was re- 
stored to the normal standard in 48 instances ; in 29 it was improved ; in 3 it remained 
unchanged ; in 3 it was rendered worse ; and in 29 cases no note was made with re- 
gard to the effect of treatment upon the hearing. This result appears in a stil 
more favorable light when we examine the cases with regard to the length of time 



DISEASES OF THE EAE. 



173 



pharyngeal catarrh. In these comparatively rare cases ' it has been my 
practice to entrust the treatment of this condition to some of my colleagues 
who are more skilled than I in operative procedures in the naso-pharyngeal 
cavity. My first experience with a case of adenoid vegetations convinced 

during which the deafness had existed. The following tables show this point very 
clearly : 

TABLE I. 



Duration of Deafness. 



No. of Cases 
treated. 



Less than 3 months. 
From 3 to 12 months 
From 1 to 2 years. . . 
From 2 to 5 years . . . 
From 5 to 10 years. . 
More than 10 years. . 
Indefinite 

Total 



10 
12 
17 
23 
21 
21 
8 



112 



Cured. 



5 

5 

9 

11 

7 
10 

1 



48 



Per cent. 



50 

41.7 

52.9 

47.8 

33.3 

47.6 

12,5 



42.9 



40.5 



TABLE II. 



The Hearing. 


<=;™r,i a n^t-^-rV, Purulent lntlani- , 

Smiple Catarrh. Total 

No. of Cases. No . of Cases. 


Was rendered normal in 


34 j 14 
18 11 
3 

3 


48 


Was improved in 

Remained unchanged in 


29 
3 


Became worse in 


3 


Was not tested in 


23 

1 


6 


29 






Total 


! 

78 34 


112 




1 







In the treatment of this form of disease, the essential thing, according to Meyer, 
is to remove the vegetations, either by mechanical or by chemical means. In chil- 
dren, and also in adults when the vegetations are not too large or too firm in texture, 
they can be destroyed by pressure made with the finger. If this mode of destroying 
them fails, we must resort to the use of some caustic, preferably the nitrate of silver, 
either in the pure form or mitigated by the addition of nitrate of potassa. The in- 
struments to be used for this purpose are silver rods, armed with a flattened end- 
piece, and differently shaped, so as to enable the surgeon to cauterize readily growths 
springing from any part of the naso-pharyngeal space. Where the growths are large, 
and especially where they are firm in texture, it becomes necessary to use other surgi- 
cal contrivances, such as the galvano- cautery, a double-bladed instrument like that 
used for crushing vesical calculi, a ring-shaped knife, etc. 

1 Speaking merely from recollection, I think I have not seen more than half a dozen 
cases in which I recognized the presence of adenoid vegetations in the naso-pharynx. 
In at least as many more cases I have probably overlooked the condition entirely. 



174 DIAGNOSIS AND TREATMENT OF 

me that chemical means alone cannot be trusted, if we wish to obtain per- 
manently successful results. As this case is an instructive one, I will give 
a history of it in brief outlines : 

A strong, healthy boy, fourteen years old, was brought to me for treat- 
ment on the 12th of June, 1874. The boy's mother stated that when he 
was three years old he had had scarlet fever, and from that time onward 
he had been subject to frequent earaches and had often shown a moderate 
degree of hardness of hearing. At times the hearing had been quite poor. 
On examination I found both drum-membranes markedly sunken and of a 
pinkish hue. Both Eustachian tubes were easily inflated, and the patient 
observed a marked improvement in the hearing immediately following the 
inflation. The pharyngeal mucous membrane was congested and swollen, 
and on the posterior wall of the pharynx there were five or six circumscribed 
elevations (enlarged follicles). On alternate days, during a period of three 
weeks, I mopped out the naso-pharyngeal cavity with a twenty-grain solu- 
tion of nitrate of silver, and applied a solution of the same strength to the 
pharyngeal portion of the Eustachian tube, by means of a bougie. I also 
employed Politzer's method regularly. At the end of this time the pharyn- 
geal mucous membrane appeared to be comparatively free from active irri- 
tation ; the drum-membranes occupied a more nearly natural position and 
had lost their former pinkish hue, and the boy appeared to hear conversa- 
tion perfectly well. I accordingly discontinued treatment. 

The following November he was again obliged to submit to a similar 
course of treatment. This time, however, the right middle ear was found 
nearly full of a thin, fluid exudation, which I evacuated through an artificial 
opening in the drum-membrane. 

On the 25th of March, 1875, he returned for the third time, and again 
I found essentially the same conditions as existed on previous occasions. 
The presence of the well-marked follicular swellings on the posterior pharyn- 
geal wall led me to ask myself whether the patient's decided tendency to 
catarrhal inflammation of the Eustachian tubes and middle ears was not 
due to the existence of similar swellings in the naso-pharyngeal cavity. 
There were also other conditions which favored such a belief ; conditions 
which up to that time had quite escaped my notice. I refer to the boy's 
peculiar expression of countenance, to his inability to breathe with the 
mouth closed, and to his muffled nasal tone of voice. As stated by Meyer, 
these symptoms point almost with certainty to naso-pharyngeal adenoid 
vegetations. In order to settle the question definitely, I explored this re- 
gion with my finger, and to my surprise found it very much encroached 
upon by a number of nodular swellings of different sizes, the largest of 
which may have been as large as a filbert-nut. As soon as I had made 
this discovery, I decided to place the patient under the care of my friend, 
Dr. Horatio Bridge, who was then practising in this city, but who is now 
living in Colorado. I cannot now recall exactly how long a time the pa- 



DISEASES OF THE EAR. 175 

tient remained under the doctor's care, but rny impression is that it was 
fully six or seven weeks. In that time he removed, little by little, a mass of 
fleshy fragments sufficient to nearly fill a two-drachm specimen bottle. If I 
remember rightly, he employed for this purpose a ring-shaped scraper, with 
a long, slender shank, and reached the vegetations with it by way of one or 
both lower nasal passages. I have also an indistinct recollection that while 
he manipulated this instrument with one hand, he guided its cutting end 
by means of the forefinger of the other hand, introduced into the naso- 
pharyngeal cavity through the mouth. I also remember that he was care- 
ful not to attempt too much at one sitting, and always waited for all inflam- 
matory reaction or soreness to subside before he attempted to remove 
other masses or portions of masses. This series of operations proved 
highly successful. The hearing returned to a fairly normal degree of acute- 
ness, and remained so for a period of at le:.:it three years (I have not seen 
the patient since 1878). His facial expression brightened up and became 
more intellectual in its stamp ; a change which was undoubtedly due largely 
to the fact that he was no longer obliged to breathe through his mouth. 

Operative procedures are also required in another and larger class of 
cases, viz.: those in which the tonsil becomes so enlarged as to encroach 
seriously upon the naso-pharyngeal space, and perhaps even upon the 
mouth of the Eustachian tube. The snail-like rate at which such a tonsil 
is likely to be reduced in size by superficial applications of either tincture 
of iodine or nitrate of silver, fully justifies the adoption, from the very be- 
ginning, of some more potent method of procedure. As I have no experi- 
ence of my own to oner with regard to the best methods of excising small 
or large portions of the tonsil, I will refer the reader to some of the more 
recent text-books on the subject of throat diseases. In cases where the 
tonsils are so large as to interfere with the proper ventilation of the middle 
ears, or where they encroach upon the pharynx to such an extent as to in- 
terfere with respiration, and consequently with the development of the 
chest, it seems to me that there can be but one opinion with regard to the 
advisability of diminishing their size as rapidly as is consistent with the 
patient's safety. In cases where the swelling of the tonsils is not excessive, 
I am disposed to question the wisdom of either excising any considerable 
portion of the tumor or of injecting iodine into its substance : the surface 
applications described above will usually be found sufficient to control the 
activity of the catarrhal process. 

In connection with the subject of treatment of the naso-pharyngeal mu- 
cous membrane, I might add that in a certain number of cases excessive 
smoking, and the frequent taking of the stronger alcoholic drinks (undi- 
luted), contribute very appreciably toward keeping the pharyngeal mucous 
membrane in an irritated condition. If the patient is allowed to continue 
these habits, the physician will find it an up-hill task to cure the aural dis- 
ease. 



176 DIAGNOSIS AND TREATMENT OF 

Tlie question which naturally suggests itself next, in connection with 
the treatment of acute and subacute catarrh of the middle ear, is this : Shall 
we endeavor to bring our remedies, either in the form of a fluid or in that 
of a spray, into direct contact with the mucous membrane of the Eustachian 
tube and middle ear, or shall we trust solely to the indirect effects which 
follow the application of these remedies to the naso-pharyngeal space ? I 
have no wish to place myself in opposition to the teachings of nearly every 
acknowledged authority in the department of practical otology, but I must 
say frankly that I have no faith in the practice of injecting fluids into the 
Eustachian tubes or middle ears. For a period of a year or eighteen months 
I used them in the manner in which I had been taught to use them in 
Vienna. I soon became satisfied, however, that in not a few cases the in- 
jections (weak solutions [gr. i. to iij. to the ounce] of sulphate of zinc, alum, 
or nitrate of silver) promoted the very irritation which I was endeavoring 
to allay ; and, in the second place, that the completeness and promptness of 
the cure were in no instance more marked than in those cases which I had 
treated without injections. Furthermore, I was always conscious that I 
was employing a method over which I could exercise but little control ; in 
fact, I never koew whether the small quantity of fluid which I had injected 
through the catheter, had entered the cavity of the tympanum, or had 
merely bathed the walls of the pharyngeal portion of the tube. With the 
view of removing this element of uncertainty from our efforts to apply rem- 
edies to the Eustachian tube, I suggested the employment of small mops 
which could readily be passed through the ordinary Eustachian catheters. x 
I gave this plan a fair trial, but I did not secure any better results than I 
did by means of the simpler method of leaving the Eustachian tubes alone. 
Furthermore, the procedure, as I am now convinced, is not a perfectly safe 
one, unless we abstain from using the stronger solutions of nitrate of silver. 
In the case of one of my patients, a gentleman, thirty-eight years of age, and 
in vigorous health, I found the tubes so obstructed that the drum-mem- 
brane on both sides, appeared to rest against the promontory. I carried 
out the simpler plan of treatment for a few days, and then, failing to accom- 
plish the desired result, I resorted to the use of the bougie, armed with a 
mop of absorbent cotton, which had been dipped in a strong solution of 
nitrate of silver (exact strength not known). I passed the bougie, armed 
with this medicated mop, about a quarter of an inch into one tube, and 
then, after saturating the mop a second time, pushed it about the same dis- 
tance into the other tubal orifice. While I was cleaning my instruments I 
noticed that the patient had grown very pale. I asked him if he felt ill, 
and he replied in the affirmative. I then took him by the arm for the pur- 
pose of assisting him to walk to the sofa, but by that time he had lost con- 



1 A Method of Using- Medicated Eustachian Bougies. Transactions of the American 

Otological Society, 1875. 



DISEASES OF THE EAR. 177 

sciousness, and simply slid from Lis chair down upon the floor. His breath- 
ing rapidly became stertorous, and he passed into a violent convulsion which 
lasted fifteen or twenty seconds. The muscles then became relaxed, and 
perfect consciousness returned, the patient expressing great surprise that 
he should be lying stretched out upon the floor. His urine was examined, 
but it was found to be perfectly normal. The unconsciousness and convulsions 
were probably due in this case to a reflex spasm of the arteries of the brain, 
dependent upon the irritation supplied by my introduction of the bougie 
(saturated with a strongly irritating solution) into the Eustachian tube. 

The employment of bougies is said to be attended by another danger, 
viz., that of lacerating the parts, and thus opening the way for the develop- 
ment of emphysema. This accident can only occur, I believe, when undue 
violence is employed in the manipulation of the bougie ; for at one time 
(1874-5) I used this instrument very frequently in private practice, in 
young children as well as in adults, and yet I have never seen a case of 
emphysema following its employment. The free end of the whalebone 
bougie should be well wrapped in cotton, so that it shall present a perfectly 
blunt, soft mass ; and if this precaution be taken, it is difficult to compre- 
hend how laceration of the parts can result from the introduction of the 
bougie unless positively rough manipulations are employed. 

The introduction of vapors into the middle ear is recommended by some 
authorities as an excellent therapeutic procedure in cases of subacute catar- 
rhal inflammation of the middle ear. Some, for example, extol the benefi- 
cial effects of "steaming" the middle ear; others recommend highly the 
introduction of the vapor of iodine, or the fumes of sulphuric ether or chlo- 
roform. With regard to all these methods of treatment, I think we should 
put to ourselves the question, Do they accomplish better results than the 
simpler methods now generally employed? If they fail to accomplish a 
more speedy or a more perfect cure, I am at a loss to see why we should 
continue to use them. The evidence which I have gathered on this subject, 
partly from my own experience and partly from that of my colleagues, points 
very decidedly to the conclusion that these methods are not more efficient 
than the simpler plans now very widely adopted. I may therefore omit 
any further detailed account of these methods, and will pass on to the com 
sideration of those other local therapeutic measures about whose beneficial 
effects there is very little dispute. 

If we exclude those methods of treatment which aim to bring the differ- 
ent remedies in direct contact with the mucous membrane of the Eusta- 
chian tube and middle ear, we virtually establish the rule that, in cases of 
simple uncomplicated acute or subacute catarrhal inflammation of the middle 
ear, all direct therapeutic interference with this region by means of drugs is to 
be dispensed with. In certain complicated cases it will be found advantage- 
ous to introduce remedies into the cavity of the tympanum, but these cases 
are quite exceptional. 
12 



178 DIAGNOSIS AND TREATMENT OF 

It is in the form of disease which we are now considering, that infla- 
tions of the middle ear, by means of compressed air, are especially efficacious. 
Whatever theory we may adopt with regard to the precise manner in which 
these inflations exert a beneficial effect, there can be very little doubt that a 
large part of this good effect is to be attributed to the restoration of the 
membrana tympani to its normal position ; — and a return of the drum-mem- 
brane to its normal position almost necessarily implies a return of the en- 
tire chain of ossicles to a normal position. Inflations, however, probably 
do good in other ways. Thus, for example, it is not unlikely that the sud- 
den rush of air through the Eustachian tube may dislodge portions of mu- 
cus which help to obstruct that channel. In the next place, the pressure 
exerted upon the cedematous mucous membrane of the middle ear and 
Eustachian tube must promote the absorption of the cellular and fluid ele- 
ments to whose presence the swollen state of these parts is due. Whether 
these speculations with regard to the modus operandi of inflations be cor- 
rect or not, the fact of their decidedly beneficial effects will scarcely be seri- 
ously disputed at the present time. 

The first practical question that presents itself in connection with the 
therapeutic employment of inflations is this : Shall we use the catheter, or 
shall we trust to what is known as Politzer's method ? As good results are 
obtained with both plans of procedure, it is not strange that the question 
should be answered differently by different men. The following considera- 
tions guide me in my choice between these two methods. As patients have 
a much greater repugnance to catheterization than to the employment of 
Politzer's method, and as the latter procedure is generally just as effective 
as the former, I always endeavor to dispense with the catheter, if circum- 
stances will permit. Furthermore, it must be remembered that the pres- 
ence of the catheter in the nasal passage and in the mouth of the Eusta- 
chian tube produces a certain degree of irritation. In a few cases I have 
observed that this irritation was sufficient to counterbalance the good effects 
of the inflations ; at all events, appreciable improvement in the condition 
of the ear and in the acuteness of the hearing did not appear in these cases 
until after I had abandoned the catheter, and restricted myself to the em- 
ployment of Politzer's method. There are cases, however, in which, for 
various reasons, Politzer's method fails to drive air with adequate force into 
the middle ear. Under these circumstances our course is clear : we must 
employ the catheter. 

The next practical question is this, How often should we employ either 
of these two methods ? To this question I can only give a more or less 
arbitrary answer. I really do not know whether it is better to inflate the 
ears several times daily, or only once a day, or even only on alternate days. 
I do know, however, that in the class of cases which we are now consider- 
ing, I obtain reasonably good results by resorting to the inflations— four or 
five successful ones at a sitting— only every other day. Too frequent in- 



DISEASES OF THE EAR. 179 

fiations may undoubtedly do harm, especially if the practice be continued 
for a period of several weeks or months ; but it would be a difficult matter 
to define the limit beyond which inflations begin to be harmful. 

It is equally difficult to lay down rules with regard to the proper dura- 
tion of such a course of treatment. In subacute cases of recent origin two 
or three repetitions of the inflations on alternate days may be found suffi- 
cient to restore the drum-membrane permanently to its normal position, to 
remove every trace of congestion or swelling, and to bring back the hear- 
ing to its former degree of acuteness. In other cases — and these perhaps 
represent the average — a course of treatment covering a period of two or 
three weeks will be found necessary for the accomplishment of the same 
results. Finally, in the more stubborn cases, I very rarely keep up syste- 
matic treatment beyond the fourth or fifth week. I prefer to give the parts 
an absolute rest of two, three, or four weeks, and then, if necessary, resume 
the inflations and the applications to the naso-pharynx. 

If, in these cases of catarrhal inflammation of the middle ear, the evi- 
dences of congestion are slow to leave the membrana tympani, the application 
of one or two leeches in front of the tragus, on alternate days, until five or 
six have been applied, will sometimes hasten recovery very materially. The 
employment of leeches, for the relief of pain, will be considered under the 
heading of Treatment, in the chapter relating to Purulent Inflammation of 
the Middle Ear. 

General measures. — In the great majority of cases the local treatment 
alone will be found sufficient for the removal of the patient's symptoms. In 
a few cases, however, we may find it necessary to resort to other measures. 
Thus, for example, I have repeatedly met with patients who were affected 
with a naso-pharyngeal catarrh (either a recent attack or an exacerbation 
of a more chronic process) which resisted all my efforts to control it. At 
the end of the third week, having failed to materially improve the condition 
of the parts, I have urged the patient to get a change of air and scene for 
a week or ten days, or even longer, if necessary. One patient visited 
Savannah, another Aiken, S. C, a third Lake George, a fourth the Cats- 
kills, and so on ; and in nearly every instance with the effect of entirely 
throwing off all active manifestations of the catarrh. Again, in some of 
these cases, there is another feature which the physician must be careful 
not to overlook. I refer to the important part which disturbed gastric di- 
gestion plays in promoting a naso-pharyngeal catarrh. Thus far I have 
observed such a relation only in rather stout, full-blooded individuals, who 
took very little exercise and yet ate heartily. Local applications to the 
pharyngeal and naso-pharyngeal mucous membrane accomplish ver} r little 
in such cases. An adequate daily amount of exercise, a diet of more easily 
digested articles of food, and the practice of daily sponging the entire sur- 
face of the body with cool water and then employing friction with a rough 



180 DIAGNOSIS AND TREATMENT OF 

towel, are the best means that I know of for eliminating whatever influence 
disturbed gastric digestion may exert upon a naso-pharyngeal and aural 
catarrh. 

Treatment of Special Stages or Conditions. 

To avoid repetition, I will say nothing at present about the treatment 
to be pursued in the painful stage of an acute otitis media catarrhalis. In 
this stage of the inflammation it is impossible to decide positively whether 
the attack will eventually be of the catarrhal or of the purulent variety. It 
seems better, therefore, in all cases to assume that the attack will be one 
of purulent inflammation of the middle ear ; and for this reason I will re- 
fer the reader to the section relating to the treatment of that variety of ear 
disease. 

The question which demands our attention more particularly in the 
present section is this : How far ought we to modify the plan of treatment 
just described, when we discover that a serous fluid or a mucoid material 
fills a large portion of the tympanic cavity '? Here, again, it is scarcely 
possible to formulate a rule that will be found generally applicable in prac- 
tice. Each case differs in some respects from the preceding one, and ac- 
cordingly, our treatment must vary correspondingly. In former years I 
followed, for a time, the practice of always incising the drum-membrane, 
and evacuating the fluid, as soon as I discovered a sufficient amount of it 
in the tympanum to apparently half fill that cavity. I very soon found, 
however, that relapses were exceedingly frequent. I accordingly modified 
the rule to this extent. I postponed making the incision and evacuating 
the fluid until after I had materially diminished the naso-pharyngeal ca- 
tarrh, and had re-established a free passage through the Eustachian tube. 
Under this regime I observed now and then a case in which the fluid con- 
tents of the tympanum gradually disappeared coincidently with the im- 
provement in the condition of the naso-pharynx ; thus rendering paracen- 
tesis unnecessary. This suggested to me the idea that the treatment em- 
ployed in the ordinary cases of catarrh of the middle ear, without effusion, 
would probably be found equally successful in those with effusion. I accord- 
ingly dismissed from my mind the idea that paracentesis was either neces- 
sary or desirable, as a means of getting rid of the effusion in the tympanic 
cavity, and adopted the practice of treating these cases in precisely the 
same manner as I do the ordinary cases, in which there is no appreciable 
amount of effusion. I have followed this practice now for several years, 
and am well satisfied with it. It is only in rare cases now that I yield to 
the temptation to make an incision and evacuate the fluid ; and even in 
some of these I have afterward arrived at the conclusion that the case would 
have got well just as quickly if I had not had recourse to the knife. 

In some of the more stubborn cases I employ counter-irritation behind 



DISEASES OF THE EAR. 181 

and below the auricle. For this purpose I use either tincture of iodine or 
the cantharidal collodion. I instruct the patient to apply, every night be- 
fore retiring, two or three coats of the iodine to the mastoid region of the 
side affected. As soon as the skin becomes uncomfortably sore, — i.e., gen- 
erally on the third, fourth, or fifth day, — the parts are to be left undis- 
turbed for two or three days, and then the iodine is again to be applied 
every night in the same manner as at first. In several cases in which I 
used tincture of iodine in the manner just described, I was disposed to be- 
lieve that the improvement which followed the employment of this remedy 
was fairly to be attributed to the property which it possesses of stimula- 
ting the absorbents to greater activity. The beneficial effects obtained 
with cantharidal collodion are undoubtedly to be attributed to this same 
property of stimulating the absorbents. I have used the latter prepara- 
tion in the following manner : I apply two or three coats of cantharidal 
collodion to the skin of the mastoid region, cover it with Husband's plas- 
ter or the rubber plaster, or with simple collodion, and then keep uj> slight 
pressure over the spot by means of a soft linen pad held firmly in position 
by a bandage or handkerchief passed over the top of the head and under 
the chin. After a distinct sac containing fluid has formed, the patient 
should remove the bandage and pad, evacuate the fluid, and then cut away 
the dead cuticle. The remaining inflamed surface should then be dressed 
for a short time with vaseline or any other simple ointment. As soon as 
the skin has returned to a comparatively normal state, the same procedure 
may be repeated. As the tincture of iodine appears to be at least as effi- 
cacious as the cantharidal collodion, and as it can be managed much more 
easily than the latter, I now use it almost exclusively under the circum- 
stances described above. 

After the different measures which I have described have been tried for 
a reasonable length of time, say for three or four weeks, without materially 
diminishing the fluid exudation in the cavity of the tympanum, we may 
with advantage resort to paracentesis of the drum-membrane, for the pur- 
pose of providing an opening through which the fluid may be driven out 
into the external auditory canal, and also, in certain cases, for the purpose 
of confirming or modifying our diagnosis. This operation, if performed 
with a reasonable degree of care by a physician who knows something 
about the anatomy of the middle ear, may be considered as perfectly safe. 
There is but one real danger, and that is this : the operator may, with the 
point of his knife, injure the delicate attachments of the anvil, or drive the 
stirrup into the vestibule with such force as to rupture the annular liga- 
ment or injure some of the delicate labyrinthine structures. However, the 
attachments of the stirrup to the oval window are quite strong, and this 
ossicle can unquestionably be handled rather roughly without serious injury 
being caused to the organ of hearing. The attachments of the hammer 
are also very powerful. On the other hand, those of the anvil are very 



182 DIAGNOSIS AND TREATMENT OF 

feeble. This ossicle is as it were suspended between the hammer and the 
posterior wall of the tympanum. The bands which attach it to the ham- 
mer are extremely delicate. From these the anvil derives little or no sta- 
bility ; but from the peculiar interlocking of the articular surfaces it derives 
probably its chief strength. At best, however, this ossicle possesses very 
feeble supports, and may easily be disconnected from the hammer by the 
manipulations of an ignorant or careless operator. In incising the niem- 
brana tympani, therefore, we should so guide the end of the slender spear- 
pointed knife that it shall not strike the end of the long process of the 
anvil or the attached head of the stirrup. All these parts which are to be 
avoided occupy, fortunately, a comparatively small portion of the area 
within which the knife can be used. This dangerous region occupies about 
half (the upper half) of the posterior superior quadrant. Hence we may, 
without the slightest fear of injuring the ossicles, begin our incision a little 
above the dividing-line between the upper and lower posterior quadrants, 
and midway between the handle of the hammer and the periphery of the 
membrane, and carry it down nearly to the lower limit of the latter. The 
membrana tympani secundaria need give us no anxiety, as it lies safely con- 
cealed in its niche of bone, quite out of reach of any straight instrument 
that might be introduced through the outer meatus. Furthermore, if the 
point of the blade be carried too far inward, the only result will be an 
incision or a punctured wound of the mucous membrane covering the 
inner bony wall of the tympanum, a result that has no significance in the 
pathological conditions now under consideration. If the fluid exudation in 
the cavity of the tympanum be serous or only slightly mucoid in character, 
such a linear or slightly curved incision as I have described will afford an 
ample outlet for its escape. But if it be more decidedly mucoid in charac- 
ter, such a mere slit will not be found adequate. A second incision must 
then be made, at right angles to and opposite the middle point of the first 
one. In making this second incision we should cut in the direction from 
the periphery toward the centre of the membrane, and not from the exist- 
ing incision backward. 

It is by no means an indifferent matter what sort of a cutting instru- 
ment is used in making an opening in the membrana tympani. In a gen- 
eral way it may be said that a spear-pointed, two-edged blade is the best 
adapted to this purpose. In the construction of such a knife— or myringo- 
tome, as it is often called — regard must be had to the relations of the drum- 
membrane to the inner wall of the tympanum. Thus, for example, it is 
safe to assume that we shall never be called upon to incise a membrane 
whose posterior half occupies a position less than two millimetres distant 
from the inner wall of the tympanum. We may also take it for granted 
that we shall never find it necessary to incise a membrane so distended 
that it occupies a position more than five millimetres distant from the inner 
wail of the tympanum. It is therefore unnecessary to have the cutting 



DISEASES OP THE EAE. 18 o 

edges of the spear-pointed knife of greater length than five millimetres, 
The myringotomes which I use have cutting edges only three and a half 
millimetres in length, and I find them amply long. In the next place, it is 
desirable that the spear-headed blade should be quite broad at its base ; the 
breadth in this case being measured from cutting edge to cutting edge. In 
children and sensitive people a single stab is often all that we can obtain, 
unless we resort to the use of an anaesthetic. Under such circumstances 
the broader the blade of our knife, the greater will be the length of our 
incision in the drum-membrane. In my instruments the greatest breadth 
is barely three millimetres. Possibly a breadth of three and a half milli- 
metres would be found better adapted to all the purposes for which a 
myringotome is used ; but we must not forget that we are often called 
upon to operate in a canal of very small calibre, and that even a slight in- 
crease in the size of the knife may be sufficient to greatly increase the diffi- 
culty of the task of operating successfully. 

It is largely a matter of individual preference whether a straight or a 
slightly bent myringotome be employed. After using both kinds, I have 
gradually fallen into the habit of using only the straight instrument. It 
seems to me that I can control such a straight myringotome more perfectly 
than I can a bent one. Those which I use are made from a single piece of 
steel, 16 ctms. long ; the slender shank together with the blade measuring 
7 ctms., while the eight-sided, roughened handle measures 9 ctms. in 
length. 

I do not remember ever to have found it necessary to resort to an anaes- 
thetic in a case requiring paracentesis of the comparatively healthy mem- 
brana tympani. The pain caused by the incision must therefore be only 
moderately acute. It is also of very short duration. As soon as it has 
subsided, we should inflate the middle ears, according to Politzer's method, 
taking the precaution first to make the patient incline the head well over 
toward the shoulder of the side on which the drum-membrane has been 
incised, in order that the force of gravity may mass the fluid directly over 
the artificial opening. In a case of simple serous exudation, one or two 
inflations almost always suffice to drive out all the fluid into the meatus ; 
but if the exudation consists of ropy mucus, the inflations alone will 
usually not be found equal to the task of expelling any considerable portion 
of the mass. Thus, for example, it is a common experience, after one or 
two vigorous inflations, to find lying just outside of the drum-membrane a 
small mass of mucus, which looks as if it might readily be removed with a 
mop of cotton ; but when the attempt is made to do this, the fact is soon 
discovered that this mass is simply a rope-like extension of a greater mass 
that still remains behind in the middle ear. It is therefore better in these 
cases to combine inflation through the Eustachian tube with suction applied 
to the external auditory canal. With Siegle's apparatus we may perform 
effective suction, and at the same time observe exactly what is taking place 



184 DIAGNOSIS AND TREATMENT OF 

at tlie perforation. We may secure the requisite inflating power by in- 
structing the patient to perform Valsalva's experiment at the moment when 
the sensation of tightness caused by the suction begins to be felt in the 
ear. In this way, by applying a pulling and a pushing force to the mass of 
mucus, we may often succeed in removing quite a large portion of it. 
There is but one way, however, in which we can be sure of removing every 
trace of mucus from the tympanum, and that is by washing out this cavity 
with tepid water. I have employed this procedure in such a small number 
of cases of well-marked otitis media mucosa that I do not feel justified in 
expressing an opinion either for or against it. In a somewhat different 
class of cases (see farther on) I have washed out the middle ear with the 
very best results, and I am disposed to believe that, in the class of cases 
now under consideration, equally good results may be obtained. I prefer, 
however, to wait until I have had further experience with the effects of 
this procedure before I recommend it to others. 

After reasonable efforts have been made to drive out the mucus from 
the tympanum, my rule has been, at least during the past four or five years, 
to allow the perforation to heal, and then to treat the case in precisely the 
same manner as if it were an ordinary case of subacute otitis media catarrh- 
alis. If we repeat our efforts to drive out the mucus, and reopen the 
wound in the drum-membrane too often, we shall be almost certain to set 
up a more or less active inflammation of the parts, and thus materially re- 
tard the patient's recovery. Individual cases, however, differ so much in 
their predisposition to inflammation, that it is scarcely possible to prescribe 
the limits beyond w T hich it is not wise to go in our efforts to free the tym- 
panum from mucus. In several instances I have had good grounds for be- 
lieving that my therapeutic interference had, in the main, done more harm 
than good. I will give here, in brief outlines, the history of one of these 
cases. 

The patient, a gentleman about forty years of age, and in a fair state of 
health, consulted me on the 5th of October, 1878, for an affection of the 
left ear. During the previous two weeks he had experienced moderate 
deafness and a feeling of fulness in the left ear, without pain. On exam- 
ination I found the mexnbrana tympani appreciably swollen, bulging pos- 
teriorly, and somewhat red. On auscultation during inflation, I heard 
crackling sounds in the left ear. I made a diagnosis of subacute catarrhal 
inflammation of the left middle ear, with considerable fluid exudation in 
the tympanum, and an unusual degree of swelling of the tympanic mucous 
membrane ; and submitted the patient to the usual treatment (inflations 
and applications to the nasopharyngeal space). In the hope of hastening 
his recovery, as he was desirous of leaving the city at an early date, I ap- 
plied a blister to the mastoid region, and prescribed a preparation of Cali- 
saya bark, to be taken internally. 



DISEASES OF THE EAE. 185 

On the 9th of October, I found the posterior half of the membrana 
tyinpani still markedly bulging. I therefore made a free vertical incision 
through the middle of the protruding portion, and was surprised to see the 
edges of the wound gape widely apart, as commonly happens when a cica- 
tricial membrane is incised. This gaping of the wound displayed to view 
a mass of opaque mucus, which apparently filled the cavity of the tympanum. 
Simple inflation by Politzer's method detached from the main mass of mu- 
cus a piece about half the size of a pea, and hurled it against the upper wall, 
half way out of the canal. This mucus had apparently lost in a great meas- 
ure its ropy character. In various ways I finally succeeded in removing 
several smaller pieces of mucus, all of them together forming a mass about 
the size of an ordinary pea. All these different manipulatioDS, as well as 
the original paracentesis, caused the patient almost no pain. In fact, the 
anaesthesia was more marked than I had ever before observed it. The mu- 
cous membrane of the middle ear, so far as it could be seen through the 
gaping perforation, presented a dull, pinkish hue, quite in harmony with 
the anaesthetic condition alluded to above. After I had removed as much 
mucus as I could from the middle ear, I touched the edges of the wound 
lightly with a bead of nitrate of silver. 

On the following day, October 10th, I found the ear perfectly quiet. No 
inflammatory reaction had followed. The parts were simply moist. 

October 11th. — Very scanty watery discharge, without the slightest ad- 
mixture of mucus. Continued freedom from pain. With a slender glass 
pipette (see p. 188) I introduced a small quantity of a ten-grain solution of 
nitrate of silver into the middle ear. 

October 14th. — No return of the mucus. Wound shows little or no ten- 
dency to heal. Slight watery discharge continues. Patient is obliged to 
leave town for a few weeks. 

November 30th. — During his absence from the city, patient has had a 
slight but constant watery discharge from the ear. Of late the discharge 
has been more abundant and thicker. On one or two occasions he experi- 
enced a moderate degree of pain in the ear, but he attributed it to the 
rough manner in which the syringe had been used. On examination I 
found the membrana tympani red, swollen, and bathed with a greenish 
pasty pus. By aid of the probe I discovered that the anterior cul-de-sac — 
the space between the drum-membrane and the anterior and lower wall of 
the meatus— was filled with a mass of granulation-tissue. I removed it 
with the snare in three or four seizures, and found that it consisted of two 
separate growths, one of them springing from the surface of the drum-mem- 
brane, close to the short process, the other from the edge of the perfora- 
tion. The membrana tympani at all points seemed to be enormously hyper- 
trophied, and noticeably so throughout the posterior half of the membrane, 
where, as seen through the large and gaping perforation, it appeared to fill 
the tympanic cavity solidly. The extraordinary course pursued by the dis- 



186 DIAGNOSIS AND TKEATMENT OF 

ease in this case led me to suspect that perhaps it was complicated by syphi- 
lis. I accordingly investigated this point thoroughly, but failed to obtain 
the slightest evidence corroborative of such a view. Nevertheless I thought 
it best to prescribe for him the following : 

Hydrarg. bichlor gr. j. 

Potass, iodidi 3 v. 

v Tine, gentian, compos § j. 

Aqu« 3 iij. 

M. S. — A teaspoonful three times a day after meals. 

December 9th. — Since the last date the local treatment has consisted in 
applications, first, of nitrate of silver in the form of a bead, and afterward 
of powdered burned alum, to the spots from which the granulations grew. 
Under this treatment the discharge diminished very perceptibly, and the 
outer surface of the drum-membrane again became smooth and firm, but 
the gaping perforation and the enormous hypertrophy of the mucous mem- 
brane of the membrana tympani still persisted apparently unchanged. As 
the iodide of potassium produced quite a decided coryza, and brought out 
a reddish eruption on the face, I abandoned the idea of a syphilitic taint, and 
discontinued internal treatment. 

A few days later the patient was again called out of town, and I have 
not seen him since. 

I have always felt that this case, which is certainly an extraordinary 
one in many respects, would have got along better if I had treated it less 
vigorously. On the other hand, I can recall a very similar case, which I 
treated at the New York Eye and Ear Infirmary in an equally vigorous 
manner, but with very different results. The drum-membrane presented 
the same bulging appearance, and upon incising it the edges of the wound 
separated in precisely the same manner as in the preceding case. Instead 
of driving out the almost gelatinous mucus which apparently filled the 
tympanum, I boldly inserted a bead of nitrate of silver through the artificial 
opening and turned it upward and backward so as to bring it well in con- 
tact with the swollen mucous membrane of that region. Four days later, 
when the patient called a second time, I found the posterior half of the 
drum-membrane flat instead of bulging, and a dry scab occupied the site 
of the incision. In the course of another week or ten days, without any 
further treatment during the interval, the parts returned to a comparatively 
healthy state, all evidences of an accumulation of mucus disappearing com- 
pletely. 

In the following case, which presented very nearly the same physical 
conditions as those observed in the two preceding cases, I tried still another 
plan of treatment. The patient, a gentleman about fifty years of age and 



DISEASES OE THE EAR. 18? 

in vigorous health, gave a history of slight deafness and a sensation of ful- 
ness in the right ear dating two months back. On examination, April 20,. 
1879, I found the right drum-membrane dull, opaque, and noticeably bulg- 
ing posteriorly and superiorly. This condition was associated with a slight 
naso-pharyngeal catarrh. The watch was heard only when pressed against 
the ear. Without going into all the details of this case I may say that on 
the 23d I made a free linear incision in the bulging posterior half of the 
drum-membrane. As the edges of the wound gaped, I could see that the 
membrana tympani in this locality was very much hypertrophied through 
swelling of its lining mucous membrane. By means of Politzer's method ' 
of inflation I drove out a limited amount of mucus. I then used combined 
suction and inflation in the manner already described, but failed to evacu- 
ate any additional mucus. Finally, I introduced a curved slender glass 
tube into the tympanic cavity, and employed suction. These efforts, how- 
ever, failed to remove any perceptible amount of mucus. 

On the 27th of April, no inflammatory reaction having followed my in- 
terference on the 23d, I removed the scab which covered the wound, and 
injected, with a middle-ear pipette, a rather strong solution of bicarbonate 
of soda into the tympanum. I assumed that there must be more of the 
thick mucus, such as I had already removed, still remaining behind in the 
tympanum ; and I thought that the solution of bicarbonate of soda would, 
in the course of a few minutes, soften it to such an extent that I should be 
able to remove a large part of it by means of Politzer's method. The ex- 
periment proved in a measure successful ; at all events, it was found, after 
inflation, that a fair amount of ropy mucus had been driven out through 
the perforation in the membrana tympani, and that the patient's hearing* 
had become somewhat more acute (H. D. W. = one inch). 

May 1st. — Patient having experienced no pain in the ear as a result of 
the procedures just described, I ventured to re-open the wound a second 
time. I found the tissues still greatly swollen, but on inflation the air es- 
caped freely through the perforation, with little or no admixture of fluid. I 
therefore decided to restrict my treatment to daily inflations of the middle 
ear (according to Politzer's method). The patient performed the inflations 
himself at his home, and presented himself for examination on the 18th of 
May. I then found that the bulging of the drum-nieinbrane had entirely 
disappeared, and with it probably the greater part of the swelling which 
had constituted such a prominent feature in the case. The patient no 
longer experienced any difficulty in hearing what was said to him, and the 
sensation of fulness in the ear had entirely disappeared. Notwithstanding 
this subjective and objective improvement, the patient could distinguish 
the ticking of my watch only at a distance of two inches. 

If the perusal of these histories of cases of otitis media mucosa leaves 
the reader in a state of doubt as to what course of treatment he should 
adopt under similar circumstances, I must confess frankly that I am not 



188 



DIAGNOSIS AND TREATMENT OF 



yet in a position to urge confidently any of the plans which I have de- 
scribed. The excellent results which have followed my comparatively re- 
cent adoption of the plan of thoroughly washing out the middle ear in cases 
of otitis media purulenta, lead me to hope that I shall find the plan equally 
successful in these cases of otitis media mucosa. Unfortunately they are 
of rather rare occurrence, and I am still waiting for an 
opportunity of testing the question for myself. Seven 
or eight years ago, after reading Hinton's monograph 
on the subject of washing out the middle ear, I made 
a single trial of the plarj, but with such disastrous re- 
sults that I have not, until recently, felt disposed to 
repeat the experiment. In the case just mentioned, 
however, I am now quite sure that the serious inflam- 
mation which followed ought not to be attributed to the 
cleansing procedure, but should rather be ascribed to 
the effects of the remedial solution (alum) introduced 
into the tympanum immediately afterward. Solutions 
of alum, no matter how dilute, are, I believe, dangerous 
to use in the middle ear. On the other hand, I have 
now used weak solutions (gr. ij. to the ounce of water) 
of nitrate of silver so often in this way that I never feel 
any anxiety about unpleasant after-effects. My idea 
with regard to the washing-out method is simply this : 
it frees the swollen and inflamed mucous membrane of 
the middle ear from its coating of mucus and other pro- 
ducts, and thus enables the physician to bring his reme- 
dial solution in contact with it at every point. 

This brings us now to the question, How shall we 
wash out the middle ear, and how shall the remedial 
solution be introduced ? For both of these purposes I 
have a decided preference for slender glass tubes, to 
which, for the sake of convenience, I have given the 
name of "middle-ear pipettes " (see Fig. 17). These 
pipettes are made from glass tubing, about three-eighths 
of an inch in diameter, and with rather thick walls. As 
these pipettes are not so very difficult to make, I will 
describe briefly the steps of the procedure. Take a piece 
of glass tubing, about eight inches in length, hold the 
ends lightly with the fingers of both hands, and rotate it slowly around its 
long axis over the blue flame of a Bun sen burner. As soon as the central 
portion of this bit of tubing has become sufficiently soft, — not at one small 
spot merely, but over a section of the tube say from half to three-fourths 
of an inch in length, — draw it out into a slender tube about ten inches long. 
As the pipette when completed should measure not less than seven centi- 




-Middle-ear 



DISEASES OF THE EAR. 189 

metres in length in its slender portion, the next step should be to file a 
shallow circular notch around the tube, at a point eight or nine centi- 
metres distant from the shoulder — if I may so designate the spot where 
the larger tube begins to grow narrower — and then break the tube at this 
spot. As it is desirable to have the tip of the pipette slightly bent, we 
should next heat it very cautiously until it bends over, from its own weight, 
in the direction that we desire it to follow. If the tip beyond the final bend 
is too long, or if the heat has caused the orifice of the narrow canal to be- 
come closed, a circular notch should be filed in the tip, at a distance of not 
more than two millimetres from the bend. To render this fractured end 
sufficiently smooth, it may either be brought sufficiently near to the Bun- 
sen flame to fuse the sharp edges, or these may be ground smooth by a 
suitable file or stone. The broad portion of the tube, if too long, should 
be filed and broken off at a distance of from three to five centimetres from 
the point where it begins to grow narrower. Before doing this, however, 
the physician should heat the tube at this shoulder and bend it at an angle 
of about 120 degrees. The rubber caps attached to the glass droppers 
usually sold by the apothecaries may be fitted in a similar manner to these 
pipettes, and will be found to answer well the purposes for which they are 
intended. 

In practice it will be found necessary to have right and left pipettes, as 
one adapted for the introduction of fluids into the right mastoid antrum 
cannot be used for this purpose in the left ear. A thud pipette, with the 
tip bent directly downward (when the instrument is held with its rubber 
cap pointing downward), will also be found useful in those cases in which 
the perforation occupies the anterior inferior quadrant of the drum-mem- 
brane. 1 

It is scarcely necessary to discuss here at length the question whether 
the curved or the straight tips are the better adapted for general use. My 
own preference is for the former. With the straight tip one is apt either 
to push it in too far, or to unintentionally draw it out of the tympanic cavity 
altogether, in both of which cases no fluid from the pipette will reach the 
middle ear. On the other hand, with the curved tip, it is possible to push 
it firmly against the mucous membrane of the promontory without there- 
by closing the aperture ; and if we draw the tip too far outward, the resist- 
ance offered by the membrana tympani gives us timely warning of what we 
are doing. Furthermore, the curved tip enables us to direct the current of 
the escaping fluid toward or into the mastoid antrum. For all these rea- 
sons I consider the curved tip decidedly preferable to the straight one. 

As glass pipettes may easily be broken, it is urged by some that these 
instruments should be constructed of platinum. Those who are unable to 



1 To obviate the necessity of going into these details a second time, I can scarcely 
avoid alluding to forms of ear disease which do not bsloiig in this section. 



190 DIAGNOSIS AND TREATMENT OF 

inake their own pipettes, or who are not within easy reach of an instrument- 
maker, cannot probably do better than to follow this recommendation. In 
the course of three or four years I have broken perhaps the same number of 
pipettes, at a total cost of not more than twenty-five cents. A good set of 
platinum pipettes, similar in all respects to the glass ones which I have de- 
scribed, can scarcely be purchased for less than twenty dollars. To very many 
men this expensiveness of the platinum instruments would prove a serious 
objection to their use. I am therefore disposed to plead strongly in favor of 
the glass instruments. One writer has said that : " In order to be available, 
such an instrument [referring to the glass pipette] must be so very delicately 
constructed that even in skilled hands it would not be entirely free from 
danger ; for, having been passed through the perforation in the membrana 
tympani, the patient, in an unguarded moment, might suddenly draw his 
head away from the operator, and the delicate hook-shaped extremity break 
off, fall into the middle ear, and its removal would certainly not be unat- 
tended with difficulty." ! The objection raised by Dr. Andrews may be 
applied with almost equal force to any instrumental manipulations about 
the drum-membrane or adjacent parts. The fact is, only those who are 
provided with "skilled hands" have any right to operate upon a drum- 
membrane or middle ear that is not acutely inflamed. 2 In the hands of 
such persons I consider the glass pipette as a reasonably safe instrument. 
I have used it a great many times, in young children as well as in adults, 
and yet I have never met with the accident to which Dr. Andrews refers. 
"Whenever I have broken a pipette it has been through carelessness in trans- 
porting it from one place to another, but never during any manipulations 
about the ear. 

As I have already stated, the middle-ear pipettes may be used either for 
the purpose of washing out the middle ear, or for that of introducing 
remedial solutions into that cavity. If our object is to only partially wash 
out the middle ear, the simplest plan is to draw the pipette full of water at 
a temperature of from 100° to 105° F., and then, after introducing the 
curved tip through the perforation, to throw the entire contents steadily 
but not too slowly into the tympanum, and preferably in the direction of 
the antrum. I usually repeat the operation a second or perhaps even a 
third time, always taking the precaution each time to mop up the fluid that 
has been driven out into the meatus. If a more thorough cleansing of the 
middle ear is thought desirable, — as in cases of otitis media mucosa, in 
which the mucus is very tough, — the best plan is to attach the pipette to 
the rubber tubing of a Clark's or fountain douche, filled with water at a 



1 J. A. Andrews, M.D., Archives of Medicine, April, 1880, New York. 

2 In cases of acute inflammation of the middle ear, the circumstances may be such 
that operative interference on the part of a person whose hands are not skilled may 
be perfectly proper. 



DISEASES OF THE EAli. 



191 



temperature of from 105° to 110° F. As the water cools rapidly in its pas- 
sage from the reservoir to the pipette, it is important not to introduce the 
instrument into the middle ear until the water has been allowed to run for 
a few moments from the curved tip. Then, compressing the rubber tube 
with the thumb and forefinger, close to the point where it is attached to 
the pipette, we should introduce the tip into the middle ear, and then, 
when everything is ready, allow the water to flow through the pipette by 
relaxing our pressure upon the rubber 
tube. A sponge held beneath the ear 
will catch all the fluid that escapes from 
the meatus. As soon as the water begins 
to flow out through the perforation, the 
exact position of the pipette can no longer 
be judged by actual inspection. It is 
therefore a matter of great importance 
that we should hold the instrument very 
steadily during the flow of water into the 
middle ear ; for if we fail to take this pre- 
caution, we shall run a great risk of in- 
juring the structures of the middle ear, or 
shall fail utterly to wash out that cavity. 
Just before the water is allowed to flow 
through the pipette we may gain some 
assistance in holding the instrument stead- 
ily in its proper position by grasping the 
slender portion with the thumb and fore- 
finger of the left hand, the remaining fin- 
gers of which find a firm resting-place 
against the patient's cheek or mastoid pro- 
cess, With regard to the quantity of 
water that should be allowed to flow 
through the middle ear, I can only assign 
an arbitrary limit, say from half an ounce 
to an ounce. At the same time I should 
not hesitate to use three or four times that quantity if I had any reason 
for believing that the smaller amouDt had failed to dislodge the mucus. 

When it seems desirable to wash out the middle ear in a more thorough 
manner than can be done with the pipette when simply armed with the 
rubber cap, I believe that Blake's middle-ear syringe (see Fig. 18) will be 
found to answer this purpose fairly well. The great objection to the em- 
ployment of a syringe for delicate work of this kind is the difficulty which 
one experiences in holding the nozzle steadily at one small spot while simul- 
taneously pushing in the piston with the thumb of the same hand. On the 
other hand, this syringe possesses, at least for cleansing purposes, the fol- 




Fig. 18. — Blake's middle-ear syringe. 






192 DIAGNOSIS AND TREATMENT OF 

lowing decided advantages over the douche and pipette : it is decidedly 
less cumbersome, and it can deliver a stream of much greater strength. 

After the middle ear has been washed out sufficiently, it is desirable to 
get rid of as much of the water that remains behind as we can. If we allow 
the water to remain, it will dilute to an unknown degree the remedial solu- 
tion employed, and thus perhaps prevent the effect desired. The better 
way is to resort to inflations immediately after the cleansing process, and 
thus remove at least the greater part of whatever fluid may be in the tym- 
panum. 

As already stated, the foregoing remarks with regard to cleansing the 
middle ear are based upon an experience with a class of cases somewhat dif- 
ferent from those which belong properly in this section. The differences, 
however, are often so slight that for all practical, and especially therapeuti- 
cal purposes, I should be perfectly justified in considering them as identical 
with those to which the term otitis media mucosa would be strictly applica- 
ble. From this standpoint, therefore, I should recommend the employment 
of only weak solutions of nitrate of silver, say of two and five grains each 
to the ounce of water, and preferably the weaker one of these two. I have 
never been in the habit of warming the solution before introducing it into 
the middle ear. If the perforation is of ample size, I fill the pipette as full 
as I can and discharge its entire contents ; if the perforation is quite small, 
I suck up into the instrument only enough to fill the slender portion of the 
tube, say one or two minims. If we use only the smaller quantity of fluid, 
it will not be necessary to pay attention to the position in which we hold 
the pipette ; but if we have drawn up into it all the fluid that its limited 
suction-power can raise, we must keep the slender arm of the pipette point- 
ing somewhat downward during the act of introducing it, or the fluid 
will soon run back into the rubber cap, and we shall simply drive out air 
into the middle ear, and thus fail in the accomplishment of our purpose. 
After the remedial solution has once been introduced into the middle ear, 
I usually allow it to remain there undisturbed and pay no further attention 
to it. Applications of this character can be made to the middle ear as 
often as three times a week. (For further details with regard to the em- 
ployment of the middle-ear pipette, the reader is referred to the chapter on 
Purulent Inflammation of the Middle Ear.) 

It is not an uncommon occurrence for the patient to ask the physician 
whether he or she cannot carry out the requisite treatment at home. Self- 
inflation — if I may so designate the act of inflating one's own middle ears 
according to Politzer's method — is not a very difficult procedure to learn ; 
but the effective application of a remedial solution to one's own naso- 
pharyngeal space is a far more difficult task, and one that very few patients 
succeed in learning. In my experience, the results obtained by self-treat- 
ment, even when the patient is a physician and thoroughly conversant with 



DISEASES OF THE EAR. 193 

the procedures to be employed, are rarely satisfactory in the class of cases 
which we are now considering. 



Chronic Subacute Catarrh. 

In this category are generally included all those cases in which the 
characteristic symptoms are : progressive deafness, noises in the ears, and 
an intact drum-membrane. If we could examine the interior of the middle 
ear and labyrinth, we should probably find that the very large number of 
cases, ' which we now, in our ignorance of the underlying pathological con- 
ditions, register under the single title of " chronic catarrh of the middle 
ear," would have to be divided into several distinct classes. Even at the 
present time we are able to recognize decided differences between these 
cases. Thus, for example, we may distinguish quite readily three fairly dis- 
tinct groups. 

In the first of these groups may be placed those cases which are char- 
acterized by evidences of congestion, and perhaps also infiltration of the 
mucous membrane of the middle ear, and by a similar condition of the 
naso-pharyngeal mucous membrane. The term chronic hypertrophic catar- 
rhal inflammation of the middle ear might perhaps be adopted as a suitable 
name for this group of cases. It is in this class particularly that we should 
be on the lookout for adenoid vegetations in the naso-pharyngeal cavity. 

In a second group the characteristic features are a very transparent 
drum-membrane (not necessarily much sunken), an apparently unobstructed 
Eustachian tube, and a smooth, thin, pale pharyngeal mucous membrane. 
The inner wall of the tympanum, as reflected through the transparent mem- 
brana tympani, appears to be unnaturally white, in marked contrast with 
the deeper coloring observed in the cases of the first group. This unnat- 
ural whiteness is due to the fact that the extreme thinness of the mucous 
membrane covering the bone allows its natural white color to be reflected 
back to the eye of the observer. On questioning such patients, we usually 
learn that at a certain period of their lives they suffered considerably from 
naso-pharyngeal catarrh. And in the light of this fact we are justified in 
assuming that the morbid process, in the ear as well as in the throat, began 
as a proliferative inflammation, with great increase in the connective-tissue 
elements, and ended in the contraction and condensation (hardening) of 
the newly formed connective tissue. In this process of contraction — usu- 
ally, I believe, called sclerosis — the glandular elements disappear, and we 
have, as the final result, an unnaturally thin, non-vascular, atrophied mucous 
membrane. The term sclerosis of the tympanic mucous membrane would 



1 As a rough estimate I should say that the cases belonging to this class represent 
at least 30 per cent, of all of the cases that apply to the aurist for relief. 
13 



194 DIAGNOSIS AND TREATMENT OF 

seem, therefore, to be a fairly appropriate one to apply to the cases of this 
second group. 

Finally in a third group may be placed all the remaining cases, the 
prominent feature of which is the absence of all discoverable lesions of 
sufficient gravity to account for the marked impairment of the hearing. 
We can simply guess at the real nature of the pathological changes in such 
cases. In some of them it is possible that the auditory nerve may be the 
part affected ; in others an anchylosis of the stapedio- vestibular joint may 
explain the deafness ; finally, in others still, the secondary tympanic mem- 
brane may have undergone thickening or calcareous degeneration, or an 
exostosis 1 may have encroached upon it. All these lesions have been ob- 
served after death, but it is easy to understand how difficult, not to say im- 
possible, it would be to recognize any such pathological conditions during 
the patient's life-time. 

We may encounter cases belonging to the first group at almost any period 
between the tenth and the fortieth or forty -fifth year of life. Those belonging 
to the second group are rarely encountered before the thirtieth year ; while 
the type of aural disease which characterizes cases of the third group may 
be seen in individuals of almost any age after childhood. In all the cases 
of these three groups the histories given are almost always the same. In 
those belonging to the first group we are apt to hear of ups and downs, 
but in those belonging to the other groups the histories all point to either a 
stationary course, as regards the hearing, or to one in the direction of more 
marked deafness. The loss of hearing may take place quite rapidly ; as a 
t— io however, the progress toward absolute deafness is a very slow one, 
emu. that extreme limit is rarely reached. The loss of the hearing may be 
a steadily progressive one for a certain period of years or months, and then, 
for many years, or for the remainder of life, it may make no further progress. 
Taken as a class, these cases are practically incurable. If our diagnosis has 
been correctly made, we may say, without hesitation, that no material im- 
provement in the acuteness of the hearing can reasonably be exj:>ected from 
treatment, except possibly in the first class of cases. In these we must as- 
sume that a certain amount of fresh disease (or an exacerbation) has been 
grafted upon the original chronic malady, and to this more recent disease 
we may direct our therapeutic efforts with some hope of moderate success. 
Then, again, there is an element of hope in another direction. The physi- 
cian sometimes (alas ! not very often) mistakes a comparatively recent and 
curable affection for one of a chronic and incurable nature. A suitable 
course of treatment soon reveals the erroneousness of the diagnosis, by 
rapidly restoring the patient's hearing. 

1 At the post-morten examination of a patient who died in the Heidelberg- Hospital, 
in 1869, I found the head of one hammer enlarged to nearly double its natural size by 
an exostosis which sprang by a broad base from the very top of this little bone. 



DISEASES OE THE EAR. 195 

The prognosis with regard to the disappearance or continuance of the 
distressing tinnitus, is just as bad as that which I have given with regard 
to the hearing. Tinnitus of long standing is, so far as niy experience goes, 
rarely cured. 

In deciding the question, in any given case, whether to undertake treat- 
ment or not, I would suggest the following course : — If the case belongs to 
the second or third group, and the patient states that the loss of hearing 
began several years previously, I should advise against treatment ; and in 
those not very rare cases, where a patient states that he can hear quite well 
in the midst of noise (as in a railroad car or an omnibus, or on a noisy street 
in one of our large cities), I should give such an unfavorable prognosis 
without any hesitation. If the case, however, belongs to the first group, 
we may give a guarded prognosis ; that is, we may say to the patient that 
we find evidences, in the ear and in the throat (naso-pharynx), that the dis- 
ease is still in more or less active operation, and that treatment alone can 
determine how much of the existing deafness is due to comparatively recent 
and curable organic changes, and how much to those of a permanent char- 
acter. We may then proceed to carry out the plan of treatment recom- 
mended on p. 165 and following pages, and if, by the end of say the third 
week, we shall not have succeeded in accomplishing at least the beginnings 
of a favorable result, we may without hesitation abandon our efforts. 

In some cases the patients seek medical advice for the tinnitus alone. 
They often say that they will cheerfully bear with the deafness if we can 
only relieve them of the distressing noises in the ears. I must confess 
frankly that I have very rarely succeeded in affording even temporary or 
partial relief for this symptom. Bromide of ammonium or bromide of 
sodium, in ten-grain doses, to be taken either after meals, or at short in- 
tervals (e.g., three or four doses during the evening), has, in my hands 
accomplished more, for the relief of tinnitus, than any other drug which 
I have tried. However, plenty of out-door exercise, a short sea-trip, or one 
among the mountains, will generally accomplish more than can be obtained 
by the administration of internal remedies. 






CHAPTER VII. 
DISEASES OF THE MIDDLE EAR— PURULENT FOBMS. 

Acute Purulent Inflammation. 
Etiology. 

As I have already stated in another place, both forms of acute inflamma- 
tion of the middle ear, the catarrhal and the purulent, rarely originate in 
any other way than by an extension of the irritation or inflammation from 
the naso-pharyngeal space along the Eustachian tube. In scarlet fever and 
small-pox, it is quite possible that the inflammation peculiar to these dis- 
eases may develop primarily in the middle ear, as well as by extension from 
the naso-pharyngeal space. However this may be, the fact remains that 
the nasal or naso-pharyngeal symptoms usually precede the aural. Scarlet 
fever stands at the head of the list of diseases which are apt to be followed 
or complicated by a purulent inflammation of one or both middle ears. 
Measles should perhaps be placed next on the list ; and then follow, in 
about the order in which I name them, small-pox, typhoid fever, cerebro- 
spinal meningitis. Another very common cause is an acute " cold in the 
head," or naso-pharyngeal catarrh. I have known heat-prostration to be 
followed by acute purulent inflammation of the middle ear. A blow, a 
fall, or a sudden concussion of the air may induce a similar inflammation. 
During the summer season, ocean-bathing, or, rather, bathing in salt water, 
figures prominently as a cause of purulent inflammation of the middle ear. 
The different method of flooding the nasal passages with remedial solu- 
tions or with simple water are all liable to produce an acute inflammation 
of the middle ear. Dr. Cornwell, of Youngstown, Ohio, in The Transactions 
for November, 1879, refers to a case that occurred in the Brooklyn Eye and 
Ear Hospital, in which an acute purulent inflammation of the middle ear 
followed the introduction of the vapor of chloroform and ether through the 
catheter into the middle ear. Finally, in addition to these, I should men- 
tion the establishment of an artificial opening in the drum-membrane as a 
not uncommon exciting cause of the change from an otitis media catarrhalis, 
with a serous or mucoid exudation, to an otitis media purulenta. 

It is held by some authorities that a diffuse inflammation of the exter- 



DISEASES OF THE EAR. 197 

rial auditory canal may extend to the middle ear, and set up there a puru- 
lent inflammation, with perforation of the membrana tympani. I do not 
remember ever to have seen a case in which this sequence of events, the 
reverse of that which we usually encounter, took place. I should feel much 
more disposed to believe in the development of an otitis media purulenta 
from an extension of an inflammation of the brain or its meninges, as is 
claimed to be a fact by some German authorities. 



Pathology. 

In my description of the acute catarrhal form of inflammation of the 
middle ear, I sjDoke of the changes observed in the drum-membrane when 
the disease had reached its highest point. These appearances are precisely 
the same as those observed in the purulent form of inflammation at a cer- 
tain stage in the progress of the disease. "While in the catarrhal form these 
appearances from that time forward steadily become less and less marked, 
until finally the druni-menibrane returns to its natural state, in the puru- 
lent variety a series of other changes first take place before the stage of 
retrogression and healing sets in. These changes, which I will now en- 
deavor to describe, are probably never all observed in a single case. On 
the other hand, an attack of acute purulent inflammation of the middle ear 
can scarcely run its course without developing one or more of them. 

In well-marked cases, one of the most characteristic changes often ob- 
served is the formation of a sac or blebs, containing a colorless or blood- 
stained serum, at the upper boundary of the drum-membrane, close to the 
short process of the hammer. Such a blebs may form at any point of the 
periphery of the drum-membrane, though it is more apt to form at the 
point mentioned than at any other. The main trunks of the blood-vessels 
of the membrana tympani congregate at this spot, and the strain upon 
them, when inflammatory stasis takes place, is probably very great. If a 
rupture of one of these vessels does not take place, the blebs formed will 
be perfectly colorless ; generally, however, a rupture does take place, and 
we then find a dark purplish tumor occupying the region of ShrapnelTs 
membrane, and concealing a part of the membrana tympani. With regard 
to the size of these cystic tumors, I may state that I have sometimes seen 
them of sufficient size to fill the inner end of the meatus and completely 
conceal the drum-membrane. In the majority of cases, however, they are 
much smaller, viz., from the size of a pin's head to that of a No. 2 shot. 
These tumors are occasionally seen in cases of acute otitis media catarrhalis, 
but they are far more common in the purulent form of inflammation. 

The development of a bulging condition of the posterior half of the 
drum-membrane is another change, which may be said to be almost always 
present in the really acute cases when they reach the proper stage. This 



198 DIAGNOSIS AND TREATMENT OF 

bulging is of course due to the pressure of the fluid exudation that is con- 
tained within the tympanum, and that is constantly increasing in quantity. 
In some cases it develops at a comparatively early stage of the attack ; in 
others it may not occur until after the tissues of the drum-membrane and 
surrounding skin of the canal have become so much infiltrated that a dis- 
tinct convexity (outward) of the posterior half of the membrane can scarcely 
be recognized. 

Simultaneously with the development of the bulging condition, and 
sometimes before that event, or independently of it, an exudation of fluid 
takes place upon the outer or free surface of the drum-membrane. At first 
this exudation causes the dermoid layer of the membrane to become white 
and opaque. Then follows a period of several hours, or two or three days, 
during which sufficient fluid is thrown off from the inflamed drum-mem- 
brane to render the external auditory canal perceptibly moist. - In this 
scanty secretion whitish flakes or masses of epidermis are usually found. 
The drum-membrane, during this period, is apt to present a whitish appear- 
ance. Ordinary syringing or mopping with the cotton-holder, armed with 
cotton, will often fail to remove this outer whitish layer, and thus a novice 
may easily be misled into believing that he is looking at a pale and unin- 
flanied drum-membrane. With the aid of the slender middle-ear probe or 
the smaller curette, one can readily satisfy himself that beneath this whit- 
ish, soaked epidermis the drum-membrane presents all the appearances of 
being intensely inflamed. At a somewhat later stage this clinging of the 
soaked epidermis to the subjacent tissues ceases to be a noticeable feature. 

The participation of the soft parts of the adjacent external auditory 
canal in the inflammation of the middle ear is an event that would be nat- 
urally expected, in view of the intimate vascular and nervous relations that 
exist between these two regions. In the less severe cases this participation 
is very slight ; in the more severe ones it may lead even to the complete 
obliteration of the osseous portion of the canal. 

Again, the drum-membrane, partly under the effects of the pressure from 
within, and partly through the melting away or death of a limited portion 
of its substance, gives way at some point, and thus affords relief from the 
tension of the fluid in the tympanum by furnishing it with an outlet. Such 
a perforation may develop at any part of the drum-membrane. One would 
expect that the part most likely to become the seat of such a rupture would 
be the central portion of the posterior half, where the tension usually seems 
to be greatest. While the tension may seem to be greater at this part of 
the membrani tympani than at any other, it is probably a fact that the ten- 
sion is equally great at all points of the membrane. If this be a fact, the 
apparent difference in tension must be due to an optical delusion, which in 
turn is probably favored by the circumstance that the posterior half of the 
drum-membrane is much nearer the observer's eye than the anterior half. 
From the fact that the perforation may occur at almost any part of the 



DISEASES OF THE EAR. 199 

membrane it is fair to assume that the rupture occurs at that spot which is 
weakest, either through a congenital or through an acquired defect in the 
nutrition or structure of the part. In scarlet fever, and perhaps also in 
small-pox, it is probable that an actual death of a limited area of the drum- 
membrane — or sometimes even of the entire membrane — has more to do 
with the development of the perforation than has the direct force of pres- 
sure. How else can we explain the enormous losses of drum-membrane 
tissue observed after scarlet fever in young children ? I once had the op- 
portunity of observing this gradual melting away of a considerable portion 
of the membrana tympani in a boy four years old. I was called to see him 
soon after desquamation had ceased, and perhaps three or four days after 
he had begun to complain of his ear. The canal was slightly moist, and 
the drum-membrane was covered with a whitish pasty material. There was 
only a moderate degree of bulging, and the boy complained very little of 
pain. In the course of one or two days I recognized the existence of a 
small perforation in the central portion of the membrane. Little by little 
this perforation increased in size until, after the lapse of about two weeks, 
it measured perhaps a full millimetre in diameter. I then lost sight of the 
child for a period of nearly one year. During this interval the mother 
had occasionally observed a slight discharge from the ear, but she attached 
very little importance to it. On examining the ear, I was surprised to find 
that the entire central portion of the drum-membrane had been destroyed, 
the opening which remained measuring easily four millimetres in diameter. 

Cases of acute purulent inflammation of the middle ear differ very ma- 
terially one from another in respect of the degree of swelling of the mucous 
membrane. In some the inflammation seems to spend itself in throwing 
out an abundant secretion froin the free surface of the mucous membrane, 
which in that event undergoes comparatively little swelling ; while in other 
cases — and these are usually the more severe ones — the mucous membrane 
becomes enormously swollen through infiltration of its tissues. It is prob- 
ably under conditions like these that the adhesions and false bands occa- 
sionally observed in the middle ear are formed. 

Finally, in every case of acute purulent inflammation of the middle ear, 
it is important to bear in mind that the communicating system of cavities, 
the mastoid antrum and surrounding cells, can scarcely escape being in- 
volved to a greater or less degree in the inflammation. At one or more 
points vessels pierce the bony roof of the tympanum, and along these the in- 
flammation spreads to the dura mater and membranes of the brain. A 
localized meningitis may be assumed to exist in every severe case of acute puru- 
lent inflammation of the middle ear ; though, as a matter of course, it is 
only in a very small minority of the cases that it spreads to the ventricles, 
involves the brain-substance proper, or becomes a more general meningitis. 



200 DIAGNOSIS AND TREATMENT OF 



Symptomatology and Course of the Disease. 

The development of pain in the ear is the most striking, if not the first 
symptom noticed by the patient. In infants, and even sometimes in chil- 
dren two or three years of age, the physician is often puzzled to know what 
ails the child, and the first hint that he receives with regard to the real 
cause of the patient's fretfulness and feverish condition is that afforded by 
the appearance of a slight discharge at the outer orifice of the ear. Teeth- 
ing is very apt to be assumed as the cause of the fever, and thus many a 
case of severe inflammation of the middle ear is allowed to run its destruc- 
tive course unrecognized and consequently unchecked. It is greatly to be 
regretted that physicians in general practice should not more frequently 
suspect an inflamed ear of being the source of these obscure attacks of ill- 
ness in children. Upon the development of a perforation, the patient often 
experiences marked and speedy relief. "I felt something give way in the 
ear, a watery discharge appeared, and the pain soon subsided," is a state- 
ment which one often hears patients make. In many cases, however, the 
rupture of the membrane affords little or no relief. This is probably due, 
in the great majority of instances, to the insufficient size of the outlet. As 
the pus can only escape under considerable pressure, when the perforation 
is small, the tension, which is the chief cause of the pain, continues and the 
patient of course experiences little or no relief from his suffering. In a few 
cases the Eustachian tube affords an outlet for some of the exudation, and 
the patient can distinctly feel the fluid trickling down the side of his naso- 
pharyngeal space. These cases, however, are comparatively rare, for as a 
rule the parts surrounding the tympanic orifice of the tube are so much 
swollen that even compressed air fails to effect a passage through it. 
Among the symptoms of minor importance may be mentioned : a sensation 
of fulness and sometimes of throbbing or pulsation in the affected ear ; 
subjective sounds of various kinds, such as roaring, singing, whistling, etc. ; 
more or less marked impairment of hearing in the affected ear ; increased 
pain when the jaws are opened and shut ; tenderness on pressure over the 
orifice of the external auditory canal, etc. The two last-named symptoms 
indicate that the inflammation has spread from the middle ear to the outer 
meatus. All these symptoms may then gradually subside, and in the course 
of ten days or two weeks from the onset of the disease the patient may be 
quite well again and free from all symptoms referable to the ear. Such 
an attack, in the course of which no alarming symptoms manifest them- 
selves, may be designated as one of moderate or average severity. 

The following case affords a good illustration of the course pursued by 
a simple, uncomplicated attack of acute otitis media purulenta : The patient, 
a boy four years of age, began to complain of pain in the right ear early in 



DISEASES OF THE EAR. 201 

the afternoon of May 30, 1877. He seemed unnaturally languid, and mani- 
fested no desire to take part in the other children's play. In the course of 
two or three hours the pain disappeared. During the night he awoke 
several times, and each time complained of his ear. 

May 31st. — Frequent paroxysms of pain, of short duration. Membrana 
tympani red and swollen ; near its posterior border, low down, the dermoid 
layer is raised into a well-marked blebs by an effusion of serum between it 
and the deeper layers of the membrane. 

June 1st. — The child slept well last night, after taking two drops of Ma- 
gendie's solution of morphine. A few paroxysms of pain during the day. 

June 2d. — Patient slept well last night without morphine. No pain in 
the ear. No appreciable heat of skin and no acceleration of the pulse ; yet 
the child refuses food, and looks pale and languid. Early in the afternoon 
the ear became quite painful, but in the course of two or three hours the 
pain disappeared again. 

June 3d. — Patient awoke this morning with a sharp earache. Pressure 
both in front of and behind the ear causes pain. The posterior half of the 
membrana tympani is now (10 a.m.) markedly bulging and of a diffusely 
red color. I incised it freely, and gave exit to a blood-stained serum. In 
less than ten minutes the child fell asleep and slept soundly until 4 p.m. 
While he was asleep the discharge from the ear — a pinkish serum — was 
constant and very abundant. At five o'clock he took food, for the first time 
in several days, with apparent appetite. The ear, he says (6 p.m.), is en- 
tirely free froin pain. 

June 4th. — The discharge is growing thicker and more like ordinary pus. 
No return of pain. Appetite good. Expression of countenance has entirely 
changed. 

June 8th. — Discharge has ceased. Drum-membrane has almost resumed 
its natural appearance. The boy seems to be perfectly well again. 

In this case the disease developed in a perfectly healthy ear. The sub- 
ject of the disease, furthermore, was a healthy child. These two facts ex- 
plain in a measure why the recovery was so prompt and complete. In 
adults, and especially in those who have passed through previous attacks 
of inflammation of the middle ear, recovery takes place as a rule more 
slowly. The following case furnishes a very marked instance of the slight 
healing powers possessed by some individuals : 

The patient, a gentleman, forty-two years of age and in fair general health, 
consulted me on the 1st of February, 1880. He said that during the previous 
two or three weeks he had been so much annoyed by a bad cold in the head 
that he had repeatedly snuffed warm salt water. He had never experienced 
any but good effects from this procedure. A few hours before calling to 
see me, however, he began to be conscious of a sensation of fulness in the 
right ear, and, as he had passed through several attacks of acute inflamma- 



202 DIAGNOSIS AND TREATMENT OF 

tion of the ear, he felt anxious lest this might prove to be the beginning of 
a fresh attack. I examined the right ear and found the membrana tympani 
slightly congested at the periphery, especially superiorly and along the' 
handle of the hammer. Watch heard at a distance of eight or ten inches. 
I advised him to send for leeches and a Clarke's douche, if actual pain 
should come on later. 

On February 2d I visited the patient at his house. He reported that 
soon after he returned home from my office the pain in the ear became 
quite severe, and continued throughout nearly the entire night. Toward 
morning he heard moist sounds in the ear, and at 6 a.m. he experienced 
simultaneously a sensation of relief from pain and a profuse outpouring of 
bloody serum from the ear. At 11 a.m., when I visited him, I found the 
pillow, the night-gown, one handkerchief, and numerous pieces of cotton- 
wool fairly soaked with the discharge. The pain had disappeared com- 
pletely. The inner end of the canal was so swollen that I could only make 
out the existence of a central perforation. The swollen parts were gorged 
with blood and looked purple. The remainder of that day the discharge 
continued to be very profuse, and still appeared like bloody serum. 

The following day (February 3d) the discharge steadily diminished and 
began to grow more yellowish. On examination with the speculum I found 
the perforation to be a little larger than the head of a pin of average size. 
The swollen walls of the canal had lost their purplish hue and were simply 
pink, and less swollen. 

From this time forward, for a period of about two weeks, little or no 
change took place in the condition of the ear. The discharge, which was 
only moderate in quantity, never became thick like pus, nor did it assume 
any of the characteristics of mucus : it remained thin and very yellow, or at 
times yellowish green. Powdered iodoform, powdered burned alum, and 
solutions of nitrate of silver of different strengths, all failed to exert any 
very marked effect upon the discharge. As the patient had been treated 
for syphilis eighteen or twenty years previously, I thought that this poison 
might possibly have something to do with the remarkable sluggishness of 
the parts, and I accordingly prescribed the bichloride of mercury (^ gr.) 
and iodide of potassium (gr. x.), to be taken three times a day. Finally, 
as a last resort, I advised the patient to visit Florida and remain there for 
one, two, or three weeks, according to the effects produced upon the ear. 
This advice was followed, and the change of climate, scene, and diet accom- 
plished what local treatment had failed to do. When the patient returned, 
after an absence of a little over three weeks, I found the drum-membrane 
healed, and the adjacent canal only a very little swollen. The discharge 
had ceased already several days previously. 

In the case just narrated I should have mentioned the fact that the pa- 
tient had been for years affected with an aggravated naso-pharyngeal ca- 



DISEASES OF THE EAB. 203 

tarrh. At the time when I examined his throat, a mass of very tough, dirty 
yellowish mucus occupied the naso-pharyngeal cavity. Beneath and around 
it the mucous membrane was very red, dry, and swollen. I made several 
applications of nitrate of silver to these parts, but the beneficial results 
produced were very slight. It was quite probable that this persistently in- 
flamed condition of the naso-pharyngeal mucous membrane contributed 
materially to keep up the inflamed condition of the adjacent tympanic mu- 
cous membrane. 

Some persons possess a decided predisposition to acute inflammation of 
the middle ear. This is particularly true of children with enlarged tonsils 
and marked chronic naso-pharyngeal catarrh. Every fresh " cold in the 
head " in such individuals usually means a fresh attack of acute inflamma- 
tion of the middle ear. If we examine their ears during the interval be- 
tween the attacks, we rarely fail to find the drum-niembrane more or less 
congested and generally drawn in beyond its proper plane. This predis- 
position is observed much less often in adults. The most striking case of 
the kind that I can recall is that of a woman, a seamstress, about thirty-five 
years of age and in apparently vigorous health, who during a period of 
about six years had at least as many well-marked attacks of acute inflam- 
mation of the right middle ear, — some of them ending in a perforation 
and a discharge of pus, others subsiding without going as far as this. I 
treated her during three or four of these attacks, and each time relieved 
her of her intense pain by freely incising the posterior half of the mem- 
brana tympani. The employment of leeches and the hot douche simply 
afforded temporary relief. After each incision the discharge of pinkish 
serum was very abundant, and the subsequent purulent discharge gener- 
ally lasted but three or four days, the membrana tympani then healing 
promptly. 

The following case affords a good illustration of a somewhat higher 
grade of inflammation. The patient, a lady about forty years of age and of 
decidedly nervous temperament, contracted a bad " cold in the head " dur- 
ing the first week of September, 1878. In the course of two or three days 
she began to experience pain in the left ear. Various measures were em- 
ployed to relieve it, and among other things leeches were applied in close 
proximity to the outer orifice of the ear. The pain, however, steadily in- 
creased, and at the time when I first saw her (September 18, 1878) it involved 
the entire left side of the head. She could hear the ticking of my watch at 
a distance of only half an inch(-f^). On inspection I found the mem- 
brana tympani slightly bulging posteriorly. The canal was perfectly dry, 
but the dermoid surface of the membrane presented a soaked appearance. 
The parts immediately bordering upon the membrane were intensely red 
and moderately swollen. Ether having been administered, I made a free 
incision through the posterior half of the membrane, and carried it upward 



204 DIAGNOSIS AND TREATMENT OF 

through a portion of the red and swollen tissues of the posterior fold. A 
sero-purulent fluid oozed through the artificial opening. 

September 19th. — The hot douche was used freely after the drum-mem- 
brane had been incised, and the patient remained free from pain for several 
hours. This morning she is again in suffering. As the douche is used 
very frequently, it is impossible to state how free the discharge is. On ex- 
amining the right ear, of which she now complains very decidedly for the 
first time, I find the membrana tympani and surrounding parts in essen- 
tially the same condition as that observed on the left side yesterday. Free 
incision of the posterior half, to be followed by the use of the hot douche. 

September 20th. — Pain in the right ear relieved; slight watery dis- 
charge this morning. Pain in the left ear was severe during the greater 
part of the night ; toward morning it diminished, and she was able to sleep 
for three or four hours. On examination I find the left drum-membrane 
concealed by a soft, pale fleshy mass which occupies the inner end of the 
meatus and appears to be attached to the central portion of the membrana 
tympani. By pulling upon it with the forceps I ascertained that its pe- 
duncle was engaged between the lips of the artificial opening in the drum- 
membrane. Further traction caused the mass to break off at the perforation. 
The discharge from the left ear, so far as I can learn, has been slight. 

September 21st. — Last evening, while I was out of town, the pain in the 
left ear became quite severe. Dr. Sexton, who was sent for, found the pos- 
terior half of the left drum-membrane markedly bulging, and re -incised it. 
The incision afforded relief, but at the present time (8 p.m.) the pain is 
again quite severe. On inspection I found a fleshy mass occupying the in- 
ner end of the left meatus. It was of a pale pinkish hue, but at one part it 
presented a decidedly red color. By pulling upon it I ascertained that its 
peduncle was held fast between the lips of the perforation. In all outward 
respects, therefore, it was like the mass previously removed. By means of 
the forceps and Blake's snare I removed all of it that was within reach. 
Under the microscope a teased specimen presented the appearance of a 
homogeneous mass of dark granules, interspersed here and there with red 
blood-corpuscles whose circular outlines were barely recognizable. In some 
places there were indistinct evidences of fibrillation. 

September 22d. — Patient passed a poor night. To-day (9 a.m.) there is 
tenderness over the squamous portion of the left temporal bone, over the 
mastoid process, and down along the left side of the neck. She complains 
of a dull, heavy pain in the left temple and eyeball. The left eye is blood- 
shot. At 8 p.m. I found the patient in so much suffering that I decided 
to convert the linear incision in the left drum-membrane into a T-shaped 
one, in the hope of affording an unobstructed escape for the exudation in 
the tympanic cavity. The patient having first been rendered unconscious 
by means of ether, I carried out this step, and also made a long and deep 
incision over the mastoid process. 



DISEASES OF THE EAE. 205 

September 23d. — By aid of opium and poultices patient passed a fair 
night. This morning (9 a.m.) I find her almost entirely free from pain in 
the left ear. The pain in the right ear continues, but is not severe. The 
discharge from both ears is still quite watery in character and not abun- 
dant. At 6 p.m. the pain in the right ear became severe. When I saw the 
patient at 7.30 p.m. I found decided tenderness over the mastoid process, 
but no oedema nor redness of the integument. Ether having been admin- 
istered, I made a free incision through the posterior half of the right drum- 
membrane and also through the mastoid integuments. 

September 24th. — Patient slept the greater part of the night, and this 
morning she seems to be every way better. The discharge from both ears 
is now distinctly purulent in character, though not abundant. 

October 1st. — Steady improvement since last note. Left drum-mem- 
brane has nearly healed, and the discharge has ceased. On the right side 
the discharge still continues, but it is steadily diminishing in quantity. 
Moderate pain at times in both ears. 

October 8th. — Eight drum-membrane has healed. Patient is now en- 
tirely free from pain. 

About ten days later I found both drum-membranes apparently nor- 
mal. So far as the patient could judge, the hearing had been entirely re- 
stored. On testing it with the watch, however, I found a slight degree of 
impairment. 

There are two or three points of interest in the case which I have just 
narrated. In the first place, linear paracentesis of the left drum-membrane 
afforded only a temporary relief from pain, and that, too, notwithstanding 
the fact that the opening, although slit- shaped, was of ample length. In 
the second place, the development of a mass of fibrinous material in the 
middle ear, and its expulsion from that cavity through the perforation in 
the drum-membrane, are events of very rare occurrence. Shall we, with Dr. 
J. Orne Green, of Boston, consider the attack as one of a high grade of 
inflammation associated with an exudation of a fibrinous material, or shall 
we consider it as one of a simple acute inflammation associated, accident- 
ally, with the formation of an ordinary clot of blood? So far as the mi- 
croscopic examination throws any light upon the question, either hypothe- 
sis may be the true one. But if we compare the peculiar conditions ob- 
served in this left ear on two different days, with those observed in hun- 
dreds of other similar cases, in many of which blood-vessels must have 
been divided just as freely as in the present case, I think we are justified 
in drawing the conclusion that Dr. Green's view is the more plausible of 
the two, and that the fibrinous masses observed were in reality exudation- 
masses and not blood-clots. 

To revert to our first point, viz., the failure of linear paracentesis to af- 
ford relief from pain, I have very little doubt that it should be ascribed to 



206 DIAGNOSIS AND TREATMENT OF 

the obstruction interposed by this fibrinous material. Steady and marked 
improvement followed the establishment of an angular opening in the 
drum-membrane. Such an opening permitted the freest possible escape 
ci all the products of inflammation, while the slit-shaped opening was prob- 
ably soon rendered useless by the accumulation of the fibrinous material 
which effectually closed it. 

The following case presents still another type of acute purulent inflam- 
mation of the middle ear, viz., one in which the mastoid cavities partici- 
pate to a certain extent in the inflammation almost from the very begin- 
ning of the attack. The patient, a boy seven years of age and in excellent 
physical condition, was attacked with a severe pain in his right ear on the 
22d of March, 1879. Various measures were tried, but they all failed to 
give more than temporary relief. On the 24th of March (9 p.m. ), when I first 
saw the patient, I found the following conditions : body temperature, taken 
in the mouth, 102° F. ; external auditory canal normal, except in the im- 
mediate vicinity of the drum-membrane, where it was red and somewhat 
swollen ; the drum-membrane itself was covered with a white, pasty coat- 
ing of epithelium, beneath which the parts were of a bright red color. Al- 
though there was no noticeable bulging of the posterior half of the mem- 
brane, I thought it better not to wait for this, but to perform paracentesis 
at once. No visible escape of fluid followed the incision. 

March 25th. — Clarke's hot douche was used freely during the night, 
but yet the boy passed a poor night, obtaining very little relief from his 
suffering. There is now a scanty watery discharge from the ear. Pressure 
over the mastoid region causes him to wince. One leech to be applied to 
this region, and the hot douche to be used freely. 

March 26th. — Another bad night. Toward morning, however, the dis- 
charge became profuse, and the pain disappeared entirely in the course of 
a few hours. 

April 2d. — Yesterday the ear again became painful. The boy had felt 
so well for several days that his parents allowed him to run about as usual. 
To-day I find him crying with pain. Inspection shows the inner end of 
the meatus to be almost closed by the swelling of the soft parts, especially 
along the upper and posterior wail. Decided tenderness over the mastoid 
process. Cervical glands enlarged. Moderate fever. Free incision of 
swollen posterior wall of the meatus. Poultices or dry heat to be applied 
externally. 

April 3d. — Pain has moderated. 

April 4th. — Continued improvement. 

(Complete recovery followed in the course of about two weeks.) 

The tenderness on pressure over the mastoid process furnished, in this 
case, good evidence of a certain degree of periostitis of that region. The 
question of its mode of origin — whether by extension from the auditory 



DISEASES OF THE EAR. 207 

canal, or by extension through the mastoid cells— is one that can be dis- 
cussed perhaps to better advantage under the head of Diagnosis. In this 
particular case I am disposed to look upon the subacute mastoid periostitis 
and upon the more acute periostitis of the posterior wall of the meatus, 
in the immediate neighborhood of the membrana tympani, as both alike 
dependent upon an inflammation whose centre of greatest activity was 
probably located in the mastoid antrum. The more serious forms of 
mastoid inflammation (both corporeal and periosteal) will be considered in 
a separate section. 

Among the most troublesome cases to manage are those in which the 
products of inflammation seek an outlet through the membrana flaccida, 
and not through the drum-membrane proper. This membrana flaccida, or 
ShrapnelTs membrane, in certain individuals is so thin and flaccid that the 
least change in atmospheric pressure in the cavity of the tympanum shows 
itself at this point sooner than in the drum-membrane. It is a common ex- 
perience to examine the ear and find a distinct hollow situated above and 
behind the short process, and then after inflation to find this same region 
converted into a rounded prominence ; while at the same time the drum- 
membrane proper shows at most only a slight change in its position as a 
whole. In such cases it is easy to understand how, under the pressure 
incident to the accumulation of an inflammatory exudation in the tym- 
panum, this particular region should, by reason of its being the place of 
least resistance, be the spot where a perforation takes place. Before an 
actual outlet is established, — that is, probably, before the last layer of the 
tissues, the dermoid, gives way beneath the pressure, — the soft parts im- 
mediately surrounding this spot display very marked evidences of a special 
irritation. They become red and swollen, and if our examination of the ear 
is made for the first time at this particular stage of the disease, we are not 
at all likely to diagnose accurately wha,t is the true state of the case. I have 
incised such swellings in the full belief that I was dividing the posterior 
half of the drum-membrane, and have only discovered my error after the 
inflammatory swelling had subsided sufficiently to reveal to me the true 
relations of the parts. The following case affords a good illustration of 
the peculiar lesions described above : 

The patient, a physician, about thirty-five years of age, contracted a bad 
cold during the first week of March, 1874 Soon afterward he began to 
experience pain in the left ear, with a moderate degree of deafness. In 
the course of two or three days a discharge made its appearance, and the 
pain at the same time became less severe. On the 17th of March, when I 
first examined the patient's ear, I found it in the following condition : the 
external auditory canal, in its outer half, was perfectly normal ; in the 
neighborhood of the drum-membrane it was red and somewhat swollen. 
After all the pus had been carefully removed, the picture presented at the 
bottom of the canal was that cf a red and swollen drum-membrane (pos- 



208 DIAGNOSIS AND TREATMENT OF 

terior half). Posteriorly and superiorly the swelling merged imperceptibly 
into the wall of the canal ; anteriorly and inferiorly quite a deep recess 
separated it from the wall of the canal. At the most prominent part of the 
swelling a slight depression, from which fluid escaped, marked the location 
of the perforation. As there was comparatively little pain in the ear, so 
long as the patient remained quiet, I decided to watch the further progress 
of the case before adopting any more active treatment than simple cleansing 
of the canal, together with occasional inflations (Politzer's method). 

On the 20th of March, finding that the swollen condition of the parts 
persisted, and assuming that the small perforation could scarcely afford an 
adequate outlet for the discharge, I made a free incision through the swollen 
tissues. 

March 23d.— Persistent pain. Discharge at times bloody. No diminu- 
tion in the swelling of the membrana tympani. Mastoid integuments, in- 
cluding the periosteum, freely incised. 

March 27th. — Decided improvement in all respects. The swelling has 
now so far diminished that I am able to distinguish quite accurately the re- 
lations of the parts. The drum-membrane proper is intact. Just above it, 
and overhanging its posterior half, is a teat-like swelling which represents 
the pouting orifice of the perforation or (more correctly) sinus. In the 
hope of diminishing the degree of resistance which the discharge must en- 
counter in escaping* through such a long sinus, I removed a large portion of 
this teat-like projection with Blake's snare. 

On the following day patient took passage on one of the Savannah 
steamers, in the hope of hastening his recovery by a change of air and 
scene. About three weeks later (April 17th) he returned to New York. The 
discharge from the ear, he reported, had ceased entirely on the 13th, and 
his general condition had greatly improved. On examination, I found that 
all evidences of active inflammation had disappeared. There was still, how- 
ever, a small conical projection of the tissues just above the posterior half of 
the membrana tympani, and at its tip (and forming part of it) was a collec- 
tion of whitish material — probably cheesy pus. There was no recognizable 
impairment of the hearing for voice-sounds and conversation, but the tick- 
ing of a watch was heard at a distance of only two inches. 

In March, 1875, every trace of the attack had disappeared, and the tick- 
ing of the watch was readily distinguished at a distance of nearly three feet. 

The pouting character of the external orifice of the sinus or perforation 
is not peculiar to perforations in Shrapnell's membrane. I have occasion- 
ally observed precisely the same condition, though on a somewhat smaller 
scale, at or near the centre of the dram-membrane. The prolonged resist- 
ance of the dermoid layer to the pressure exerted by the pus is probably 
as much the cause of the pouting condition here as it is in the region of 
Shrapnell's membrane. 



DISEASES OF THE EAE. 209 

A few words more with regard to perforations in generaL In my own 
practice I have never known more than one perforation to form in the mem- 
brana tympani as a result of an acute inflammation of the middle ear. That 
two perforations may occur, however, in the same membrane, is clearly shown 
by the fact that occasionally, and particularly in dispensary practice, we 
find drum-membranes perforated in two places, or presenting two well- 
denned cicatrices — evidences of the former existence of perforations. Fi- 
nally, I have seen one case in which the fluid exudation found an outlet 
for itself, not through the drum-membrane proper, nor through the soft 
parts above the membrane, but at some point below it. It is hard to con- 
ceive how this could have taken place, and yet the evidence in this case 
pointed very clearly to the existence of a channel of communication between 
the tympanic cavity and a collection of pus in the external auditory canal. 



Sequelce and Complications. 

The more important sequel* of an acute purulent inflammation of the 
middle ear are : inflammation of the mastoid process (corporeal and peri- 
osteal), meningitis, and chronic purulent inflammation of the middle ear 
with its very numerous lesions. These sequel* possess the importance of 
independent diseases, and I will therefore consider them in separate sec- 
tions. The only affection of any importance that can be considered as a 
complication of an acute otitis media purulenta is abscess of the meatus. I 
have before me the incomplete notes of five such cases. In three of these 
the abscess was located near the outer orifice, and was circumscribed or 
furuncular in its nature. In the other two a collection of pus formed be- 
tween the skin (i.e., periosteum) and the bone at the inner and upper por- 
tion of the meatus, close to the drum-membrane. In these two cases it 
seems to me more than likely that a partial perforation took place in Shrap- 
nell's membrane, and that the pus, instead of forcing its way directly 
through the tissues which form the outer limit of this region, burrowed a 
way for itself between the soft parts and the bony wall of the meatus. As 
I did not see these cases, however, until after the collection of pus had 
formed (toward the end of the second week of the disease), I cannot speak 
very positively with regard to this point. In the three cases of circum- 
scribed abscess of the canal, the first symptoms of this complication did not 
show themselves until after all the acute manifestations of the middle-ear 
inflammation had subsided. In all three cases I felt confident that the 
abscess was not a legitimate outgrowth or complication of the original dis- 
ease. In the first case, for example, the abscess was induced, as I believe, 
by the use of the solution of the acetate of lead, and in the second by the 
employment of burned alum ; while in the third case it owed its origin to a 
local eczema confined to the outer half of the meatus, and which needed only 
14 



210 DIAGNOSIS AND TREATMENT OF 

the irritation supplied by the discharge from the middle ear to fan it into 
an acute circumscribed inflammation. 

The participation of the cervical and post-auricular glands in the in- 
flammatory process is a noticeable feature in quite a large proportion of the 
cases of acute purulent inflammation of the middle ear. I have never 
known this sympathetic inflammation, however, to go beyond the point of 
producing a moderate degree of swelling and tenderness of the affected 
glands. 



If called to see a person who is suffering with an acute inflammation 
of the middle ear of recent origin, we shall probably at first be obliged to 
lirnit our diagnosis to the simple establishment of the fact that the disease 
is inflammatory in its nature and to the determination of the locality in 
which the inflammation is taking place. The disease, we can say, is an 
acute inflammation of the middle ear, but whether it will go on to the for- 
mation of pus, or whether it will recede after reaching some point short of 
this stage, are questions which cannot surely be answered at such an early 
stage. As our treatment is not based upon the character of the exudation 
which is thrown out into the middle ear, we may safely wait for circumstances 
to reveal the facts with regard to the point in question. If the disease has 
not progressed so far as to involve the external auditory canal to a marked 
extent, it is scarcely possible to err in our diagnosis. Even without actual 
inspection, the patient's account of the attack — in the case of an adult — 
generally gives us some idea of what peculiar part of the ear is the seat of 
the inflammation. Actual inspection of the parts, however, can scarcely 
fail to remove the last element of doubt, I can think of but two possibili- 
ties of error : first, an inflammation of the soft parts lining the osseous por- 
tion of the external auditory canal and the outer aspect of the drum-mem- 
brane may easily be mistaken for an acute inflammation of the middle ear 
that has involved (secondarily) the inner half of the meatus ; and secondly, 
the whitish appearance of the dermoid surface of the drum-membrane, con- 
cealing perfectly — as it often does— the underlying inflamed tissues, may 
mislead an inexperienced observer into the belief that he is looking at an 
opaque, thickened, and uninflamed membrana tympani. The first error 
can only be avoided by a careful sifting cf all the evidence. An acute in- 
flammation of the middle ear causes more decided deafness and far more 
pain than does an inflammation of the osseous portion of the canal. Again, 
the order in which the different symptoms have followed each other furnishes 
us with valuable aid in deciding which of the two diseases is the one that 
is under observation in any given case. To avoid the second error, it is 
simply necessary to demonstrate, by actual manipulation of the parts, — that 
is, by the use of the slender probe, the curette, or the cotton-holder, armed 



DISEASES OF THE EAR. 211 

with a small mop of cotton, — that the surface under observation is a part of 
the living tissues, and not a pasty, dead exfoliation. 

In infants and young children we must rely almost entirely upon what 
Ave can ascertain by actual inspection. The mother's account of the symp- 
toms observed is usually very vague, at best. On the other hand, primary 
acute affections of the meatus are very rare at this early age. 

If we limit our diagnosis, in the class of cases under consideration, to 
the mere determination of the locality in which the inflammation is going 
on, our task— judged from the standpoint of practical utility — is but half 
completed. In order to treat the case intelligently and successfully, we 
should push our researches much farther. We should have before our minds, 
for example, a reasonably clear picture of the limits of the inflamed area and 
of the amount of damage already done by the disease. The color of the 
drum-membrane, the extent to which it is disfigured, the flatness or rotundity 
of its movable portions, especially its posterior half, and the degree of in- 
flammatory disturbance in the adjacent cutaneous walls of the canal, all fur- 
nish valuable means of estimating the degree of vigor displayed by the in- 
flammation, and the degree of tension or pressure to which the soft parts 
lining the middle ear are being subjected. Having ascertained tjiese facts 
with more or less accuracy by direct inspection, our next step should be to 
try and learn to what extent the inflammation has spread froni the tym- 
panic cavity to adjacent parts. Has it spread in the direction of the cranial 
cavity ? The severity of the pain in the head, on the same side as that of 
the affected ear, affords a rough means of measuring the degree to which 
the congestion of the adjacent meningeal vessels has progressed. Without 
insisting too much on the value to be attached to the following statement, I 
may say that I have been disposed to consider the change from a simple 
unilateral headache to one more distinctly localized in the occipital or frontal 
region as an evidence that the meningeal congestion has materially in- 
creased in degree and extent. I have observed this phenomenon so often 
in the more serious cases of inflammation of the middle ear that I think 
some diagnostic value should be attached to it. Has the inflammation 
spread to the mastoid region ? Pain referred to this region, redness, and 
perhaps swelling of the skin covering the mastoid process, and tenderness 
on pressure with the finger, these are the symptoms which indicate that 
the mastoid process is participating in the inflammatory process. In this 
same group of symptoms may be placed another, viz., redness and swelling 
of the posterior and upper wall of the meatus, in the immediate vicinity of 
the drum-membrane. Finally, the determination of the patient's body 
temperature may serve to confirm the opinion that we have formed from the 
other methods of examination employed. In children we may confidently 
expect to find an appreciable elevation of the body temperature in all cases 
of acute inflammation of the middle ear ; in adults we also usually find some 
elevation of the body temperature, but, as I know from personal observa- 



212 DIAGNOSIS AND TREATMENT OF 

tion, this elevation may be markedly disproportionate to the serious char- 
acter of the damage that is being wrought in and around the ear, and 
particularly in the cranial cavity. It is therefore unsafe in adults to infer, 
from the insignificance of the rise in temperature, that the case is progress- 
ing well and that no harm need be feared. 

The existence of a perforation may be learned by direct observation or 
by auscultation while air is being forced into the middle ear. If the per- 
foration is small, or if the membrane has not been thoroughly dried with 
the mop of cotton- wool, it may be impossible to distinguish the situation of 
the perforation by simple inspection. As a rule, we can readily discover 
the point of rupture in such cases by asking the patient to perform Valsal- 
va's experiment while we watch the behavior of the drum-membrane. Even 
then the perforation may be so small that we can simply distinguish the 
oozing of a little fluid from a certain portion of the drum-membrane. With 
the slender probe, however, we can always demonstrate the precise spot occu- 
pied by the opening. The presence of fluid exudation in the external audi- 
tory canal is not to be taken as satisfactory evidence of the existence of a 
perforation. It may be, and very often is, simply an exudation from the 
outer surface of the drum-membrane and adjacent inflamed walls of the 
oanaL 

Prognosis. 

An acute purulent inflammation of the middle ear, if allowed to run its 
course unchecked, will undoubtedly, in the majority of cases, do so without 
serious detriment to the patient. In the minority of cases, however — and 
it is by no means a small minority — the disease produces more or less seri- 
ous damage. An impairment of hearing of variable degree, a chronic and 
generally offensive discharge from the ear, and even fatal disease of the ad- 
jacent organs, are the prominent items in the catalogue of damages that may 
result from an unchecked acute inflammation of the middle ear. These 
facts are now so well known to the profession that I certainly may be ex- 
cused from the necessity of furnishing satisfactory evidence of the truth of 
what I say. There was a time, however, and that too within the memory 
of some of the younger men in the profession, when an acute inflammation 
of the middle ear was looked upon in a very different light ; it was gener- 
ally considered as one of the diseases of minor importance, and it was ac- 
cordingly allowed to run its course practically unchecked. As a result of that 
regime of professional ignorance and indifference with regard to diseases of 
the ear, there were, and are still in this city alone, thousands of individuals 
affected with chronic discharge from the ear. In those days, therefore, the 
prognosis of an acute purulent inflammation of the middle ear — if based 
upon the facts of actual observation — must necessarily have been unfavora- 
ble, or at least very guarded in its nature, especially where the disease origi- 



DISEASES OF THE EAR. 213 

nated in one of the exanthemata. During the past few years, however, a 
very noticeable change has taken place in two particulars. In the first 
place, the majority of the better class of practitioners now recognize the 
danger of allowing an acute inflammation of the middle ear to run its course 
unchecked. If they do not feel competent to manage this class of diseases 
themselves, they call to their assistance some professional brother who is 
familiar with their treatment. In the next place, the number of physicians 
who are competent to treat a case of acute otitis media has very greatly in- 
creased. While these remarks apply more particularly to the city of New 
York, it is, I have reason to believe, true also of other cities and towns. 
There is therefore no lack of men who know how to prevent the disastrous 
results which sometimes flow from an acute inflammation of the middle ear. 
These important changes, both in the state of professional opinion and in 
that of professional skill, have already led to a marked change in the prev- 
alence of the bad types of chronic purulent inflammation of the middle 
ear. I speak now entirely from my own personal observation ; and in ac- 
cordance with that I may say that, if we compare the material observed be- 
tween 1870 and 1875 with that observed between 1875 and 1880, a very 
noticeable diminution will be found to have taken place, in the latter peri- 
od, in the proportion of cases affected with really serious chronic disease of 
the middle ear. There is but one plausible interpretation that we can put 
upon this fact, viz., that the treatment of this disease in its acute stage has 
been better conducted during the latter than during the former period. In 
fact, it is not an exaggeration to say that under proper treatment, if begun 
soon, i.e., toithin a few days after the onset of the attack, an acute inflammation 
of the middle ear rarely results in the patient's death, or seriously impairs the 
hearing of the affected ear, or passes into a really chronic purulent inflamma- 
tion. At the present time, therefore, the aurist, or the general practi- 
tioner who has acquired the special knowledge and skill which the treat- 
ment of these cases demands, may give a very good prognosis in cases of 
acute inflammation of the middle ear, provided he be not sent for after se- 
rious damage has actually been inflicted by the disease. There is scarcely 
another department of practical surgery in which the physician can boast of 
greater triumphs than those attained at the present day in the treatment of 
acute diseases of the middle ear. 

The physician is often asked to state the probable duration of an attack 
of acute inflammation of the middle ear. The answer must of course de- 
pend upon the severity of the attack, upon the age and condition of health 
of the patient, upon the degree of inflammation and hypertrophy of the 
naso-pharyngeal mucous membrane, upon the exciting cause of the disease, 
upon the surroundings and mode of life of the patient, and upon various 
other circumstances too numerous to mention. Assuming that all these cir- 
cumstances are favorable, we may estimate the probable duration at from ten 
days to three weeks in the cases of average severity, and at from four to 



214 DIAGNOSIS AND TREATMENT OF 

six weeks in those of a more virulent type. In young and healthy children 
recovery takes place more quickly than in adults. In persons who have 
passed the middle period of life, the return to a healthy condition of the 
parts is apt to be slow. In individuals of a consumptive type our progno- 
sis, especially with regard to the duration of the subsequent discharge from 
the ear, must be very guarded. In these individuals the mucous membrane 
of the middle ear seems to possess little or no recuperative power, and the 
discharge may continue for weeks or months, in spite of our best efforts to 
arrest it. In cases of acute inflammation of the middle ear following scar- 
let fever or measles we must expect a less prompt recovery, as a rule, than 
is generally observed in cases which owe their origin to a " cold." 



Treatment. 

The different therapeutic measures employed in the management of an 
acute inflammation of the middle ear may be discussed under three heads, 
viz., those measures which tend to arrest or diminish the direct force of the 
inflammation, those which tend to prevent its indirect effects, and those 
which possess the power of arresting the purulent discharge which follows 
the acute stage of the disease. 

I. Therapeutic measures which tend to arrest or diminish the direct force 
of an acute inflammation of the middle ear. — It does not often happen that 
we are called to see a case of acute inflammation of the middle ear at such 
an early stage of its development that we can prevent it from going through 
all the different stages of an ordinary attack of otitis media purulenta acuta. 
If a young child, four or five years of age, complains of pain in the ear, the 
mother is apt to send for a physician without very much delay ; and this 
explains why a majority of the individuals in whom we have the satisfaction 
of seeing the inflammation subside, under the employment of suitable re- 
medial measures, without going on beyond the first stage, are children of 
about this age. The practical question which naturally suggests itself in 
this connection is this : by what evidences or symptoms are we to know 
whether we should employ the milder abortive methods of treatment, or 
whether we should, without further loss of time, proceed to more heroic 
measures ? Or, to put the question somewhat differently, up to what time, 
judging from the evidences obtained by direct inspection and from the 
patient's own sensations, can we safely and properly postpone the operation 
of establishing a vent in the membrana tympani ? As paracentesis is per- 
formed almost solely for the purpose of relieving the great pressure exerted 
upon the membrana tympani and the mucous membrane of the middle ear 
by the fluid exudation that is being poured into that cavity, we may an- 
swer the question by stating that so long as the drum-membrane, and par- 
ticularly its posterior half, does not display what is termed a " bulging " 



DISEASES OF THE EAE. 215 

condition, we may safely persist in our efforts to arrest the inflammation 
by means of the various antiphlogistic measures which I am about to de- 
scribe. The only limitation that I would place upon this rule is this : if, 
by reason of the swelling of the adjacent parts, we are unable to decide 
positively whether bulging of the membrane exists or not, we should estab- 
lish the opening and thus give the patient the benefit of the doubt. 

In the early stage of the inflammation, while there is simply redness 
and swelling (infiltration) of the tissues, I know of nothing more potent to 
quiet the pain and check the further progress of the inflammation than hot 
water } if kept in contact with the drum-membrane for a certain length of 
time. In children over four years of age Clark's douche armed with the 
pronged nozzle, described on p. 33, can be used very readily. By keep- 
ing the reservoir only slightly raised above the level of the patient's ear, 
and by renewing its contents from time to time, we can keep a steady but 
gentle current of hot water flowing over the outer surface of the drum- 
membrane. As a rule this continuous poulticing of the deeper parts of the 
ear affords the patient marked and prompt relief. In a few cases, however, 
some form of dry heat — e.g., flannel pillows or bags containing hot bran, 
hot salt, or hot sand — seems to afford greater relief than does the douche. 
In this connection I should state that much of the ill-success experienced 
by physicians in the employment of the hot douche is due to the imperfect 
manner in which the operation is performed. It is almost useless to give 
the patient's mother or friend an order on some apothecary or instrument- 
maker for the requisite apparatus, and then to accompany this order with a 
verbal explanation of the way in which the instrument should be used. 
Under such circumstances there are very few chances that the apparatus 
will be managed in such a way that the current of water will ever go be- 
yond the cartilaginous portion of the meatus. The physician should per- 
sonally superintend the carrying out of this procedure, when it is done for 
the first time, and he should satisfy himself that the person to whom it is 
entrusted is competent to perform the task efficiently. In favorable cases 
relief from pain may be obtained in the course of fifteen or twenty minutes, 
or even sooner. As soon as relief has been obtained, the douche should be 
withdrawn, and warm applications (dry or moist, according to the patient's 
preferences) should be made to the outside of the ear. If the pain returns, 
the use of the douche should be resumed. If, after a fair trial — say for a 
period of fifteen or twenty minutes — no appreciable relief is obtained by 
the employment of the douche, it is better to abandon it altogether. 

Another, fully as effective, but far simpler plan of poulticing the drum- 
membrane, is to pour water of a temperature of about 100° F. into the ex- 
ternal auditory canal. For this purpose an ordinary teaspoon, or better 
yet, a glass dropper may be employed. The water must be poured into the 
ear, as a matter of course, while the patient is lying upon the opposite side, 
with the affected ear turned upward. A large vessel containing hot water 



I 



216 DIAGNOSIS AND TREATMENT OF 

should be near at hand, so that hot wet cloths may be quickly laid over the 
ear before the water in the meatus has had time to cool. As an additional 
means of retaining the heat as long as possible, dry flannel cloths (heated, 
if possible) may be laid upon the moist ones. In the course of a few min- 
utes, the cloths are to be removed, the water is to be allowed to escape 
from the ear, and a fresh supply is to be introduced in the same manner 
as at first. As already stated, I have found this very simple procedure 
fully as effective as the more complicated plan of keeping the drum-mem- 
brane constantly bathed by a running stream of hot water. 

Local bloodletting, by means of leeches applied near the orifice of the ex- 
ternal auditory canal, or in the angle just behind the auricle, stands perhaps 
next in order as a means of alleviating the pain and checking the inflam- 
mation. In children it is better to abstain wholly from the use of leeches in 
combating an acute attack of inflammation of the middle ear. Even in adults 
I am much less disposed than formerly to place faith in their power to pre- 
vent such an inflammation that is still in its first stage, from going on 
through all its stages. In a later stage of the disease, after a purulent dis- 
charge has set in, leeches will often produce effects which every other thera- 
peutic measure has failed to accomplish. Farther on we will refer to this 
matter again. So far as the number of leeches to be employed is concerned, 
I may say that in a fairly strong and healthy adult it is of very little use to 
apply less than four. If there are no conditions which contraindicate such 
a course, it is a good plan to allow the after-bleeding to continue for at least 
half an hour. In applying leeches under these circumstances the same in- 
structions hold good as those which were given in Chapter IV. (see p. 73). 

It is not at all unlikely that dry cups might be used to advantage in 
checking an acute inflammation of the middle ear. In persons with hairy 
necks it would of course be difficult or even impossible to apply them until 
the hair had first been shaved. I have never used dry cups in the treatment 
of ear diseases, and merely mention them now as means which might under 
circumstances be used to advantage. 

Some authorities recommend the employment of ice, in the form of an 
ice-bag, which is to be applied to the outside of the ear. As I have had no 
personal experience with this method of controlling an inflammation of the 
middle ear, I may be permitted to pass on at once to the consideration of 
other matters. 

An acute inflammation of the middle ear is almost invariably aggravated 
by physical exercise on the part of the patient. Rest, or the avoidance of 
physical exercise, is therefore a very important agent in diminishing the 
virulence of this disease. A man in active business does not like to remain 
quietly at home simply because his ear is somewhat painful, and the phy- 
sician often finds difficulty in convincing him that by pursuing such a 
course he will in the end economize time. Again, at a later period, after 
the acute symptoms of the disease have apparently subsided, patients are 



DISEASES OF THE EAR. 217 

apt to resume business too soon, and in this way they may bring on a re- 
lapse which may prove even more serious than the original attack. Young 
children, during the onset of the disease, show very little disposition to 
play or to take any form of exercise, xlt a later stage, however, the pre- 
cautions referred to above are very necessary. The moment the child is 
relieved from pain and has had the requisite amount of sleep, the desire 
to resume play manifests itself in an unmistakable manner. Eestraint 
should be exercised under these circumstances, and the child should be al- 
lowed to regain its full measure of freedom in this respect only gradually. 
I am disposed to attach a great deal of importance to this matter of rest 
in the treatment of acute affections of the middle ear. I do not mean by 
this that I consider it necessary for the patient to go to bed and remain 
there until every trace of the inflammation has subsided, although in certain 
cases this will be found to be the better course to pursue ; but simply that 
he should not walk about to any extent, that he should not go up and down 
stairs, that he should not ride in a carriage or omnibus over our rough city 
pavements, that he should not transact any business that is calculated to 
engross his attention very seriously, and so on. All these things excite 
the heart's action or cause a jarring of the inflamed and sensitive mucous 
membrane of the middle ear, and, if they are persisted in, renewed inflam- 
mation is likely to be the result. Some of the worst cases of inflammation 
of the ear that I have seen clearly owed their protracted and violent course 
to the patient's disregard of this well-established principle in the treatment 
of inflammatory affections. 

Stress has been laid by some authorities on the value of position as a 
means of diminishing the severity of an acute inflammation of the ear. I 
have never made a serious effort to ascertain whether or not some one po- 
sition of the body favored the subsidence of the inflammation sufficiently 
for us to utilize this knowledge in our treatment of this class of cases. 
Patients very soon discover for themselves what is the position of body in 
which they experience the least pain, and they naturally select that posi- 
tion by preference. 

The diet during the acute stage should of course be of a non-stimulat- 
ing character. This is a matter, however, which generally regulates itself, 
as the patient is not apt to have sufficient appetite for any but the lightest 
kind of food. 

2. Therapeutic measures which tend to prevent the indirect effects of an 
acute inflammation of the middle ear.— In the preceding section I have enu- 
merated the various measures that may be employed to arrest or diminish 
the direct force of an acute inflammation of the middle ear. These are the 
measures which we shall probably find it advisable to use when we are first 
called to see the patient, unless we find that the disease has already gone 
beyond what might properly be called the first stage. If we bear in mind 






218 DIAGNOSIS AND TREATMENT OF 

what is the direct purpose of these different measures, — I refer more par- 
ticularly to the employment of the hot douche and leeches, and to the 
abstinence from physical exercise,— we shall appreciate at once the fact 
that they may come into requisition, not simply during the first stage of 
the disease, but at other times during its course. During the first stage, 
however, our entire reliance is placed upon these measures, and if they fail 
to arrest the progress of the inflammation, there will come a time when 
other measures will be found necessary, — measures wiiicn have for their 
chief object the relief of the pressure and tension caused by the fluid exuda- 
tion that is being poured out into the cavities of the middle ear, and also 
to a less extent into adjacent soft parts. We will suppose, then, that in a 
given case we have tried one or more of the methods of treatment recom- 
mended in the preceding section, and have failed to relieve the pain or to 
arrest the disease. What is to be done next ? The proper course to pur- 
sue is generally indicated in a very clear manner. The inflammation in its 
further progress has by this time either caused the drum-membrane (the 
only part of the middle ear that we can see) to swell greatly, through in- 
filtration of its tissues, or to bulge outward through the pressure of the 
free inflammatory exudation contained in the tympanic cavity. In either 
case an incision through the drum-membrane is what is most urgently 
needed. The longer the pressure is allowed to continue, the greater the 
danger of those various sequelae which may be described roughly under the 
titles of mastoid disease, inflammation of the brain, and chronic discharge 
from the ear. The incision should be made in the posterior half of the 
membrane, and its character should depend upon the condition of the parts. 
For instance, if the membrane is simply bulging and there is not much in- 
filtration of the tissues, a linear incision will suffice. In unruly young chil- 
dren, we are often compelled, unless an anaesthetic has first been adminis- 
tered, to be satisfied with a mere stab of the membrane. Such a stab, 
however, if made with a properly constructed paracentesis-needle (see p. 
182), usually suffices. In adults, a longer incision (say four millimetres 
in length) is desirable. It should be made deliberately, with or without 
the aid of an anaesthetic, according to the patient's ability to bear the pain 
without flinching. If both the drum-membrane and the adjacent soft parts 
in the meatus are, so to speak, fused into an unrecognizable swollen mass, 
or if good evidence exists that the inflammation has already spread to the 
adjacent parts, a single linear incision can scarcely be trusted to afford 
adequate relief. It is better then to convert the linear into a crucial or 
T-shaped (a X turned over on its side) incision. My plan is to introduce 
the point of the needle as high up as I dare in the swollen tissues of what I 
deem to be the posterior half of the drum-membrane, to cut downward a 
distance (roughly estimated) of about four millimetres, then to turn the 
blade of the needle and carry the incision directly backward until I meet 
with bony resistance. 



DISEASES OF THE EAE. 219 

In speaking of paracentesis of the drum-membrane, under the head of 
mucous or serous accumulations in the tympanic cavity, I said that I rarely 
found it necessary to employ an anaesthetic, the pain of the operation 
being quite bearable. In the case of an acute inflammation of the middle 
ear the parts are much more sensitive, and paracentesis under these cir- 
cumstances is decidedly painful. I am therefore often obliged to employ 
an anaesthetic ; certainly not in the majority of cases, but yet in a very re- 
spectable minority of them. When the severity of the inflammation seems 
to demand a crucial rather than a linear incision, I urge the patient to take 
an anaesthetic. As it is important to use the knife deliberately and cau- 
tiously, when we are compelled to operate without the aid of the usual 
landmarks (short process and handle of hammer, and outlines of the per- 
iphery of the membrane), it is far better to wait until the patient is per- 
fectly unconscious, so that we may have simply the unavoidable difficulties 
of the operation to contend with. The dangers that beset the operation 
have already been stated on p. 181, and it is not necessary to allude to them 
again in this place. 

Immediately after the operation I am in the habit of filling the auditory 
canal with as hot water as the patient can readily bear, and then of apply- 
ing externally a large sponge or several thicknesses of flannel cloth wrung 
out of hot water. The heat and moisture relieve the pain caused by the 
incision and favor the establishment of a discharge from the inflamed tis- 
sues. At intervals of five or ten minutes these hot applications should be 
renewed, as they retain their heat for only a short time. As soon as the 
pain has been relieved, all active therapeutic interference should cease un- 
til a free discharge has set in. Then the ear should be douched or syringed 
gently two or three times a day, for the purpose of removing the pus from 
the auditory canal before it has time to become foul. In cases that run a 
favorable course, if the discharge is steadily diminishing in quantity, the 
ear need not be douched or syringed so frequently. It is particularly dur- 
ing this stage of recovery from an acute attack of otitis media purulenta 
that intelligent and faithfully carried out douching or syringing contributes 
so largely toward a speedy healing of the perforated dimm-membrane. In 
young children this simple operation of keeping the ear clean will, in the 
great majority of cases, be found sufficient, treatment with drugs being 
required in only a few instances. 

3. TJierapeutic measures which possess the power of arresting the discharge 
which follows the acute stage of a purulent inflammation of the middle ear. — In 
a large proportion of the cases the discharge from the ear, which sets in 
after the acute stage of the inflammation has subsided, disappears so 
rapidly that the methods referred to under this third heading are not called 
into requisition. In a certain proportion of the cases the discharge continues 
for a longer period than is perhaps generally observed under similar circum- 



220 DIAGNOSIS AND TREATMENT OF 

stances. If I were asked to state what should be considered as the normal 
duration of the discharge in these cases of acute otitis media purulenta, I 
would say one week for the milder cases, and two or three weeks for the 
more severe ones. By this I mean that the physician is perfectly justified 
in not adopting direct measures for the arrest of the discharge until it has 
run on unchecked for a week in the milder cases, and for two or three 
weeks in the more severe ones. While the selection of the time when it is 
proper to interfere actively in the treatment of this stage of the disease is 
a more or less arbitrary affair, there are nevertheless a few points which 
serve as aids to us in reaching a decision. In the first place, the patient, 
or the patient's parents, may express the desire to have the discharge 
arrested as soon as possible. Our course, under these circumstances, is 
very clear. We should proceed at once to adopt such measures as will 
accomplish the result desired. There is one rule, however, that comes 
into play in this connection, and it is a rule that cannot safely be dis- 
regarded : never make any attempt to arrest or diminish the discharge so long 
as pain persists. I usually employ nothing but the warm douche or syring- 
ing with warm water until a full week has elapsed from the time when the 
patient last experienced pain in the ear. If at that time the discharge is 
steadily diminishing in quantity, I prefer — unless urged by the patient to 
adopt more active measures — to trust a little longer to the simple plan of 
cleansing the ear. If nature is working out a cure in a reasonably rapid 
manner, why should the physician interfere? After a second week has 
elapsed, however, and the discharge is still more or less active, I feel no 
hesitation in advising the adoption of measures calculated to arrest the 
discharge. 

If we wish to treat successfully a case of otorrhcea or discharge from 
the ear, we must picture to ourselves clearly the precise locality from which 
the discharge comes. In the disease which we are now considering the 
discharge is supplied chiefly by the mucous membrane lining the tympanic 
cavity, and to a less extent by that lining the mastoid antrum and adjacent 
air-containing cells. This mucous membrane is diseased, and to restore it 
to a healthy condition we must bring our remedies in direct contact with 
it. This is the problem which we, as physicians, are called upon to solve. 
If a large perforation has formed in the drum-membrane, the problem is 
comparatively easy of solution. As a rule, however, the perforation is 
quite small, sometimes even invisible. How, then, are we, under these cir- 
cumstances, to bring our remedies in contact with the tympanic mucous 
membrane ? As there are but two routes by which the tympanic cavity 
can be reached, we must select one or the other of these. That by way 
of the Eustachian tube is encompassed with various difficulties, that is, if 
we attempt to use it for the purpose of bringing fluids in contact with 
the tympanic mucous membrane. That by way of the perforation in the 
drum-membrane is therefore practically the only route that we can follow. 



DISEASES OF THE EAR. 221 

Having chosen our route, let us next consider the practical details of the 
operation of bringing our remedial solutions in contact with the diseased 
tympanic mucous membrane. In the first place, we may assume that the 
cavity of the tympanum is filled with fluid exudation. Our first step should 
therefore be to remove this secretion as thoroughly as we can. If the per- 
foration is sufficiently large we can wipe out some of the fluid by means of 
the cotton-holder ' armed with absorbent cotton. Inflations by means of 
Politzer's method will also aid materially in freeing the tympanic cavity 
from any secretion that it may contain. In the natural order of things, 
however, the inflations should precede the use of the cotton-holder. In the 
majority of cases the cleansing that is effected by one or both of these 
methods will be found sufficiently thorough for our purposes. A more per- 
fect method will be described farther on. If the perforation be very small, 
we may find it desirable or even necessary to enlarge it with the paracente- 
sis -needle. This enlarging of the perforation is specially indicated in cases 
in which the discharge is mucoid in character ; for in these cases the secre- 
tion cannot be forced through a small perforation, unless a greater degree 
of force be used than is proper. After we have removed as much fluid as 
we can from the middle ear, our next step should be to introduce our reme- 
dial solution as thoroughly as possible into this same cavity. A simple and 
fairly effective way of accomplishing this is the following : the patient should 
hold his head in such a position that the affected ear will be turned up- 
ward. The remedial solution should then be dropped into the auditory 
canal until it covers the drum-membrane to a depth of at least five or six 
millimetres. In order to force a part of this solution through the perfora- 
tion, pressure must be exerted from without upon the mass of fluid as a 
whole. This can be done in two ways. With one hand the physician 
should pull the auricle outward (i.e., away from the head), with the fore- 
finger of the other he should press the tragus backward in the same 
manner as he would shut the lid of a box, and then, relaxing his hold on 
the auricle, he should press the tragus firmly inward toward the drum- 
membrane. In this way quite a strong pressure can be brought to bear 
upon the fluid that lies upon the outer side of the drum-membrane. It is 
well, however, not to trust to this pressure alone, but to take advantage of 
the aid which the patient (if an adult) is able to afford by performing the 
act of swallowing (with or without simultaneous closure of the nasal ori- 
fices). When I resort to this method of forcing fluid into the middle ear, 
I make it a rule to lessen the pressure the moment the patient experiences 
either pain or dizziness. I also cease to make pressure as soon as the pa- 
tient notices that some of the solution has reached the naso-pharyngeal 
space. A Politzer's rubber bag, armed with a nozzle that will fit the orifice 
of the external auditory canal in an air-tight manner, affords another means 

1 The smallest size of instrument should be used for this purpose. 



222 DIAGNOSIS AND TREATMENT OF 

of condensing the air in the meatus, and of forcing the remedial solution 
into the middle ear. After I have succeeded, by one of these two methods, 
in introducing the remedy into the tympanum, I usually allow it to remain 
there undisturbed for two or three minutes, and then I have recourse to 
Politzer's method of inflating the middle ear for the purpose of dislodging 
the solution from that cavity. I am now disposed to believe that when 
quite weak solutions are used, it would be better not to attempt to dislodge 
the remedy, but to leave it undisturbed in the tympanum. 

The methods which I have just described are fairly effective in dimin- 
ishing and eventually arresting a discharge from the middle ear. In not a 
few cases, however, they seem to exert but very slight curative effects ; and 
if we seek for the reasons why they fail to produce these effects, we find 
either that the middle ear has not been adequately cleansed, thus prevent- 
ing the remedial solution from coming in contact with the mucous mem- 
brane, or that the solution has really never passed through the perforation 
into the cavity of the tympanum. 

A much more satisfactory plan of treating these cases is that by means 
of the middle-ear pipettes described on p. 188. This method, which in 
skilled hands is simply invaluable, often arresting the discharge as it were 
by a single stroke, is unfortunately beyond the reach of the average prac- 
titioner. It is only after a man has acquired delicacy and steadiness in his 
manipulations, skill in the management of the forehead-mirror, and thorough 
familiarity with the region of the middle ear, that he may safely undertake 
to treat a case by aid of the middle-ear pipette (no matter of what material, 
platinum or glass, the instrument be constructed). With regard to the 
mode of using this instrument in the class of cases now under considera- 
tion, there is very little to say in addition to what has already been said in 
the section relating to otitis media mucosa (see p. 190 et seq.). If the dis- 
charge is not mucoid in character, the preliminary cleansing described above 
will usually be found sufficient. The curved end of the pipette is then to 
be introduced into the perforation, and the remedial solution is to be in- 
jected into the tympanic cavity. These injections should be repeated on 
alternate days, or three times a week ; and if, after the third or fourth in- 
jection, little or no improvement is perceptible, we may safely assume that 
our treatment is defective in respect to the preliminary cleansing. The 
proper course is then to wash out the middle ear in one of the two ways 
described on pp. 190 and 191, and immediately afterward to introduce the 
remedial solution. 

Of the different local remedies that may be used in the treatment of a 
non-chronic purulent discharge from the middle ear, I employ only nitrate 
of silver, in the form of solutions of different strengths. In the great ma- 
jority of cases it is not necessary to employ a stronger solution than one 
containing two grains to the ounce of water. If the perforation is compar- 
atively large, say about two millimetres in diameter, we may — if the weaker 



DISEASES OF THE EAE. 223 

solutions fail to produce the desired effect — employ a solution of almost 
any strength, e.g., one of even 480 grains to the ounce (saturated solution). 
In this connection I may say that during the past two or three years I have 
rarely felt the necessity, even in the chronic forms of purulent discharge 
from the middle ear, of employing a stronger solution than one of five 
grams to the ounce. I almost never introduce the remedial solution into 
the tympanum in any other way than by means of the slender glass pipette, 
and it is to this more perfect method of bringing the remedy in contact 
with the diseased tympanic mucous membrane that I attribute the success- 
ful results which I have obtained with such a weak solution as one of two 
grains to the ounce. It may seem strange to some who read this section 
that I should recommend solutions of only one drug, viz., nitrate of silver. 
I do it, however, advisedly, for I have wasted a great deal of time in trying 
various remedies, — all of them highly recommended ; but I have found them 
one and all so far inferior to nitrate of silver that I feel no hesitation in 
passing them all over in silence. 

Unless the perforation is quite large, it is practically useless to recom- 
mend the patient to employ some remedial solution at home. If for any 
reason, however, it seems desirable to do so, a three-grain solution of sul- 
phate of zinc or a two-grain solution of acetate of lead, may be prescribed. 
The solutions of nitrate of silver can scarcely be employed by the patient 
himself, — or by the mother in the case of a child, — for without a certain 
degree of familiarity with the handling of these solutions, almost anybody 
would be quite certain to stain either his person or his garments. 

The more rebellious cases of otitis media purulenta acuta merit the title 
of otitis media purulenta chronica, and it is to that chapter that I would 
refer the reader who desires to learn further details with regard to the 
management of this class of cases. 

If the perforation is large enough to admit of such a procedure, pow- 
dered remedies (alum, iodoform, boracic acid) may sometimes be used to 
advantage in checking the discharge from the middle ear. My mode of 
using them is the following : the tympanic cavity having been freed as 
far as possible from the secretions which it may contain, I moisten the tip 
of the slender middle-ear probe, dip it into the powder, and then cautiously 
introduce it, with the mass of powder clinging to it, into the opening in the 
drum-membrane. In the case of a small opening I generally find it neces- 
sary afterward to push in, one after another, the portions of powder that 
remain sticking to the edges of the perforation. Sometimes a single such 
charge of powder suffices to arrest the discharge permanently ; at other 
times, repeated applications will be found necessary. So far as the quantity 
is concerned, I am not aware that it is important to employ any particular 
amount of either of the three remedies mentioned above. In the case of 
powdered burned alum, a mass equal in size to a No. 8 shot (or a sphere 
about two millimetres in diameter) will often suffice for a single charge. I 






224 DIAGNOSIS AND TREATMENT OF 

frequently, however, use three or four times this amount, especially if the 
perforation be one of good size. I have never experienced any unpleasant 
effects from using powdered burned alum in this manner. In former years 
I was in the habit (in chronic cases, with extensive destruction of the drum- 
membrane) of blowing comparatively large quantities of powdered alum in- 
discriminately into the exposed cavity of the middle ear, and I occasionally 
experienced unpleasant effects. This mode of procedure, however, is very 
different from the one recommended above. In the scale of efficiency I 
should place powdered iodoform very nearly if not quite on a par with pow- 
dered burned alum ; in the scale of safety I should place both it and bora- 
cic acid ahead of the alum. The penetrating odor of the iodoform is some- 
times so disagreeable to the patient, or to the patient's friends, that the 
physician is obliged to abstain from its further use. Apart from this it is 
a most valuable remedy. Boracic acid, in the form of a very fine sand, — I 
have not yet succeeded in obtaining a finely divided powder, — seems to 
produce its beneficial effects by robbing the secretions of all their irritating 
properties, and not by exerting anything like an astringent effect. I have 
not used it very much in the manner described above, and am therefore 
scarcely competent to express a decided opinion with regard to its efficiency. 
In its direct curative powers, I am confident that it will be found inferior to 
both alum and iodoform. I frequently prescribe it, however, as a deodor- 
izer, instructing the patient to add it to the water used for syringing the 
ear, in the proportion of a scant teaspoonful to the pint of water. I am not 
positive that I can yet say very much in its favor even as a simple deodor- 
izer, though in the main I have been pleased with the results obtained. 

Acute Inflammation of the Posterior Fold of the Drum-Membrane. 

I have seen only two cases of this rare form of disease, and as both the 
subjective symptoms and the changes observed in the ear are almost the 
same as those which characterize certain forms of acute inflammation -of 
the middle ear, I have thought it best to say what little I have to say on 
this subject in the present chapter. The history of the first of these cases 
is as follows : 

The patient, a policeman, consulted me on the 10th of March, 1874, for 
a very distressing tinnitus in both ears. He had experienced no pain in 
them, and his hearing, so far as he was aware, was perfect. The tinnitus 
had made its appearance about two months previously. I tested his hear- 
ing with my watch and found it to be : E. T \ ; L. j%. Both drum-mem- 
branes presented a dull and opaque appearance, and were slightly sunken. 
On the left side there was moderate congestion of the posterior fold (the 
parts above and behind the short process of the hammer). My diagnosis 
was catarrhal inflammation of both middle ears, and I began treating the 
patient in accordance with that diagnosis. 



DISEASES OF THE EAK. 225 

On the 14th of March, finding that the redness of the posterior fold 
still persisted, I painted the parts with a strong solution of nitrate of silver 
(gr. 120 to the ounce). I interpreted this redness as an evidence of a still 
more active congestion of the neighboring mucous membrane, and em- 
ployed the solution of silver simply for the purpose of producing a deriva- 
tive effect. 

On the 16th the patient reported that the tinnitus in the left ear had 
materially increased : there was, as he described it, a constant ringing of 
bells in his ear. His face presented the aspect of one who was in suffering, 
but yet he described the pain in his ear as being only trifling. H.D. W. = 
Xj. _s_ On inspection I found that the skin immediately above the poste- 
rior half of the drum-membrane was red, tense, and glistening. Through 
the upper and posterior portion of the membrana tympani, which was still 
translucent, a yellowish area was visible. It conveyed to my eye the ap- 
pearance as if a yellowish body projected downward from the inner side of 
the axis-band of the hammer. Suspecting the existence of an accumulation 
of pus, I incised the inflamed and swollen posterior fold, and afforded es- 
cape to a drop of thick, creamy pus. A second incision into the anterior 
fold, which was also quite red, gave escape only to blood. (The patient 
bore both of these cuts without flinching.) Inflation by Politzer's method 
failed to exert the slightest appreciable influence upon the contents of the 
abscess. After the immediate pain of the incisions had subsided, the pa- 
tient expressed himself as feeling greatly relieved in the condition of his 
head. 

On the 18th of March the patient reported that he was feeling better, 
and that no discharge had yet made its appearance ; and on inspection I 
found that no evidence existed of there having been any discharge since the 
day of the operation. 

On the 23d of March only a slight singing noise remained in the left 
ear. (The subsequent history of the case is of no further interest in its 
bearings upon the subject of the present section.) 

The second case was seen about two years later, and from that time to 
the present I have not seen a third case. The history, in brief, is as fol- 
lows : The patient, a lady, about thirty years of age and in good health, 
began to suffer from pain in her right ear on April 18, 1876. Her physi- 
cian examined the ear, and finding it filled with a plug of cerumen, he re- 
moved it by syringing. During the following three days she continued to 
suffer from pain in the ear, the pain not being constant, but coming on in 
paroxysms, with intervals — which sometimes lasted for several hours — of 
complete freedom from pain. The pain, however, when it came, was of very 
great severity, especially on the 21st of April, the day on which I saw her. 
At this time I found the external meatus in a normal condition ; the drum- 
membrane was beginning to be slightly cedematous (like polished steel 
15 






226 DIAGNOSIS AND TKEATMENT OP 

when breathed upon), but not appreciably reddened ; the posterior fold was 
red and somewhat swollen, especially posteriorly, but without any appreci- 
able pouting, as if pus were working its way toward the surface. Hearing 
distance for watch ^. A free incision (about four millimetres in length) 
made in the posterior fold caused quite a large drop of pure, thick pus 
to almost gush out through the opening. (The patient was under the influ- 
ence of an ansesthetic. ) 

I did not see the case again, but the physician reported that the opera- 
tion gave complete relief, and that very little, if any, discharge made its ap- 
pearance afterward. 

In the report which I published of these two cases, in the Transactions 
of the American Otological Society for 1877, 1 made the following remarks : 
" Every aurist sees a number of cases of otorrhcea in which the only demon- 
strable lesion of any importance is an ulcerated opening in the posterior 
half of Shrapnell's membrane, from which a fistulous track leads inward a 
variable distance, and at the bottom of which the probe usually encounters 
denuded bone. Sometimes this opening is so extensive that the neck and 
head of the hammei he exposed to view. The peculiarity of these cases, 
however, lies in the fact that the membrana tympani is still entire, and, in 
many cases, not adherent to the inner wall of the tympanum. Inflation, 
too, either by Politzer's method or by means of the catheter, reveals the 
fact that the cavity of the tympanum contains no fluid, and has no commu- 
nication with the fistulous cavity. In other words, the trouble is a chronic 
caries of a limited region of bone in the immediate vicinity of the middle 
ear ; but it differs from all the most common forms of caries encountered 
in this region in the fact that the pus and detritus thrown off from the dis- 
eased part do not escape by way of the tympanum, but through a sinus 
which, though appearing to lead directly into the middle ear, has no com- 
munication whatever with this cavity. If I am not mistaken, it has been 
customary to explain these cases on the supposition that originally there 
was an inflammation of the entire middle ear, with a perforation in Shrap- 
nell's membrane, but that gradually the inflammatory process became re- 
stricted to the tissues occupying the upper and posterior portion of the 
cavity, the wall of separation formed by the healing process being so per- 
fect as to entirely prevent any of the inflammatory products from entering 
the middle ear. In a word, these cases have been looked upon as cases of 
an imperfectly healed purulent inflammation of the middle ear. The two 
cases which I have just reported suggest the idea that the pathology of this 
class of cases may be a different one ; that is, that at the outset the inflam- 
mation may have been restricted to the soft parts constituting, and lying 
near to, the posterior half of Shrapnell's membrane [posterior fold is meant]. 
As the descriptions of these two cases show, such a circumscribed inflam- 
mation of Shrapnell's membrane does sometimes occur, and, such being the 



DISEASES OF THE EAE. 227 

fact, is it not more natural to explain these cases of fistulous opening in 
Shrapneirs membrane as ab initio cases of circumscribed inflammation? 
Further observations of such cases will undoubtedly furnish us, in due 
time, with a satisfactory explanation of their pathology." Further observa- 
tions have not been forthcoming, and from this circumstance alone I am 
convinced that the view which these two cases strongly tempted me to 
adopt is not the correct one, at least so far as the majority of cases of 
ulceration of Shrapnell's membrane is concerned. Furthermore, it is dim- 
cult for me to get rid of the idea that an irritation from without — sup- 
plied, in the one case, by the application of a strong solution of nitrate of 
silver, and in the other by the pressure very probably exerted by the mass 
of impacted cerumen — may have determined the localization of the inflam- 
mation in this particular region. 

So far as the diagnosis of an abscess in the posterior fold is concerned, 
the following may be mentioned as the points which will enable us to sus- 
pect strongly that pus is developing in this particular locality : 

1. The well-marked redness of the parts which lie immediately above 
the posterior half of the drum-membrane. 

2. The absence of any evidence of active inflammation of the middle 
ear proper. 

3. The unusual severity of the pain in the ear. 

4. The slight degree of impairment of the hearing. 

5. The absence of pain, tenderness, or swelling in the mastoid region, 
one or all of which symptoms would be present if the redness of the pos- 
terior fold were simply an evidence of the more acute inflammation going 
on in the mastoid antrum. 

6. The previous history of the case can alone enable us to differentiate 
the condition under consideration from that produced by a fracture of the 
squamous portion of the temporal bone. 

The treatment has already been sufficiently indicated above. 

Syphilitic Disease. 

Writers on diseases of the ear are, I believe, nearly unanimous in the 
statement that lesions characteristic of syphilis are never observed in the 
middle ear or membrana tympani. While I do not feel justified as yet in 
disputing this statement with any great degree of positiveness, owing to 
the scantiness of the material which has come under my observation, I 
cannot help feeling that, we shall in time learn to recognize in these parts 
textural lesions as distinctively characteristic of syphilis as are most of its 
external manifestations. Take for example the following cases : 

Case I. — The patient, a gardener, thirty-seven years of age, was in good 
physical condition when he first came to the Infirmary, on the 25th of Sep- 



228 DIAGNOSIS AND TKEATMENT OF 

tember, 1872. He stated that seven years previously lie first noticed that 
his hearing was diminishing in acuteness. The deafness increased very 
slowly, and there was constant tinnitus aurium. When I first saw the pa- 
tient I was obliged to raise my tone of voice a little in order to make 
myself heard by him. The ticking of my watch was heard at a distance of 
three inches on the right side, while on the left side he could only hear 
it when the watch was pressed against the ear. Pharyngeal mucous mem- 
brane pale and " sclerosed." Both drum-membranes opaque and somewhat 
whitish in color, but perfectly normal in position. 

Treatment (twice a week) : inflations, according to Politzer's method ; 
mopping out the naso-pharyngeal space with a twenty-grain solution of 
nitrate of silver. 

October 9th. — Pharyngeal mucous membrane is now red and somewhat 
swollen. 

November 20th. — Ten days ago, according to his account, he began to 
suffer from pain in the left ear. Three days ago a serous discharge made 
its appearance, and has continued since. On examination, the left drum- 
membrane is found to be red and swollen, with a small perforation in the 
anterior inferior quadrant. The handle and short process of the hammer 
are no longer distinguishable. No bulging of any part of the membrane. 

November 26th. — Perforation has apparently healed. Otorrhoea has 
ceased. During inflation the air is heard through the auscultation-tube to 
enter the middle ear in a continuous current, without rales. The drum- 
membrane is still red, swollen, and parchment-like on its outer surface. 

December 4th. — To-day the right drum-membrane is found to be red 
and swollen. No history of pain in the ear. 

December 7th. — Eedness of right drum-membrane less marked. 

December 14th. — Condition of the left drum-membrane has again 
changed. It is now of a bright red color, moist, more decidedly swollen 
than at the last visit, and covered in front with a thick white mass, sugges- 
tive of a growth of vegetable fungus. Examined under the microscope, 
however, this mass is found to be composed entirely of large, flattened epi- 
thelial cells. Perforation again visible in the anterior inferior quadrant. 

December 18th.— Swelling of left drum-membrane has again diminished. 
Perforation is barely recognizable as a black point. 

January 15, 1873. — Pharyngeal mucous membrane is still red and 
swollen. Patient complains of constant pain in the ears. He can no longer 
distinguish the ticking of a watch in either ear. A perforation has also 
formed in the right drum-membrane. A well-defined circular white spot 
has developed, since the last visit, in the posterior superior quadrant of the 
left drum-membrane. 

January 29th. — Pain continues. A second perforation now exists in the 
left drum-membrane ; it is located at the site of the circular white spot 
noticed at the last visit. 



DISEASES OF THE EAE. 229 

March 5th. — Patient has not visited the Infirmary since the last date. 
His general condition has very much changed during the interval. He is 
emaciated. His face wears constantly an expression of pain. Pulse rapid 
and feeble. He states that he has suffered a great deal since his last visit 
with pain throughout the left side of the head. Discharge from the left ear 
copious and fetid. Total . loss of hearing in the left ear. The tones of a 
vibrating tuning-fork are referred to the right ear, even when it is placed 
upon the left temporal bone. At the innermost portion of the left meatus 
the upper cutaneous wall of the canal appears to be in a collapsed condition. 
By means of a probe this collapsed portion can be lifted back nearly to its 
natural position, though not sufficiently at all pomts to bring the membrana 
tympani into view. When passed farther in the probe encounters quite an 
extensive region of denuded bone. No special change has taken place in 
the right ear, except that the hearing is so poor that we are obliged to 
communicate with him by writing. 

June 25th. — Patient is barely able to walk about without assistance, owing 
to his feeble condition. Left side of face paralyzed. Tongue swollen and 
ulcerated. He admits to-day, for the first time, that ten years ago he had 
a chancre, followed soon by sore throat and other characteristic symptoms. 
He has been an inmate of one of the large general hospitals of the city for 
several weeks past, and declines to enter the Infirmary. (This was his last 
visit to the institution.) 

Case H. — Male, twenty-four years of age, well nourished. He was seen 
for the first time on the 9th of October, 1878. Double otorrhcea of several 
weeks' standing. No history of anything like an acute beginning, nor does 
he remember to have ever had otorrhcea before the present attack. Syphi- 
litic ulceration of velum ; diffuse redness and swelling of entire fauces. 
Eight external auditory canal filled with pus. The membrana tympani, 
after the removal of the pus, was found to be of a bright red color, very 
much swollen, and perforated in two places — below and in front, and pos- 
teriorly near the umbo. A whitish material filled the posterior perforation. 
In a word, the drum-membrane presented jDrecisely the same appearance, 
as regards color, condition of ulceration, diffuse swelling, etc., as did the 
soft palate. (No note was made of the condition of the left ear, and the pa- 
tient was seen for the last time a few days later.) 

The development of a second perforation in the left drum-membrane of 
Case L, through a melting process similar to that observed so frequently in 
the velum palati, is totally different from anything that I have ever observed 
in any case of non-syphilitic infiammation of the middle ear. In Case H. 
probably this same melting away of a limited area of the drum-membrane 
took place, though in that case I only had an opportimity of observing the 
process at its stage of completion. There were no evidences of pressure 



230 DIAGNOSIS AND TREATMENT OF 

from within in either of these cases ; in both, the loss of substance could 
only be described as a melting away or death of the tissues. In Case I., 
furthermore, the subsequent course of the disease — the development of 
caries and facial paralysis, with no evidences of interference with the free 
escape of the pus formed — was certainly not in harmony with the ordinary 
course of a non-syphilitic otitis media purulenta acuta. 

In all the other cases that I have seen of inflammation of the middle ear, 
of syphilitic origin, the picture presented by the membrana tympani was 
invariably the same as that which we frequently see in the non-syphilitic 
cases. 

With regard to the question of prognosis and treatment, a word or two 
will suffice. The prognosis is the same as that of a corresponding syphilitic 
lesion in any other part of the body. Aside from the administration of 
constitutional remedies, the treatment is the same as that employed in an 
ordinary case of acute purulent inflammation of the middle ear. 1 



Cheonic Pueulent Inflammation. 
(Otitis media purulenta chronica.) 

Etiology. 

A chronic purulent inflammation of the middle ear begins almost invari- 
ably as an acute inflammation. In tuberculous and syphilitic individuals 
we may observe an insidious and painless development of the disease in the 
middle ear, but these cases are comparatively rare. The etiology of chronic 
purulent inflammation of the middle ear, so far at least as it can be said to 
have an etiology separate from that of the acute variety, may be summarized 
in a single sentence : the lack of proper treatment during the acute stage 
of the inflammation is the cause of the chronic form of the disease in ninety- 
nine out of a hundred cases. This may seem somewhat exaggerated. 
Nevertheless, I believe it to be true. There are many cases, I admit, which 
yield very slowly to even the most skilful treatment, and which perhaps 
would be described as having merited the title of " chronic ; " but the total 
duration of the affection is even then not likely to exceed a few weeks, 
whereas a genuine case of chronic otitis media purulenta is one in which 
the morbid process in the middle ear has been going on for months, if not 
for years. It is to cases of this kind that I refer when I say that they owe 
their origin, as a rule, to the lack of proper treatment during the earlier 
stages of the attack. 

1 See a recent paper on this same subject by Dr. F. R. Sturgis, in the Boston Medi- 
cal and Surgical Journal, June 3, 1880. 



DISEASES OF THE EAR. 231 



The Course of the Disease. 

A chronic purulent inflammation of the middle ear may run a variety of 
courses. For years the mucous membrane of the middle ear may secrete a 
scanty purulent or muco-purulent fluid, and if the patient is careful to 
cleanse the ear at stated intervals, this persistent but slight otorrhcea may 
represent the only symptom of which he has any complaint to make. Fur- 
thermore, the most careful examination may fail to detect any evidence of 
the existence of any other pathological condition than that of a slightly 
swollen and relaxed J tympanic mucous membrane ; I except, as a matter of 
course, the loss of drum-membrane substance that took place undoubtedly 
in the earlier stages of the disease. If this perforation in the membrana 
tympani is of ample dimensions, it is not likely that the pathological picture 
which I have described will undergo any material change for the worse. 

In another group of cases this placid course of the disease is disturbed 
by a complication which may lead to a whole train of more or less serious 
disorders. I refer to the development of granulation-tissue. Two elements 
co-operate in certain cases to bring into activity this proliferative tendency : 
first, the acrid and irritating nature of the secretions ; and second, the 
uncleanly habits of the patient, who permits these acrid secretions to He 
undisturbed, in a decomposing condition, in contact with the mucous mem- 
brane of the middle ear. Sometimes the irritating properties of these se- 
cretions are so great that even the skin lining the external auditory canal 
undergoes ulceration from contact with them. In this second group the 
discharge is almost always abundant. 

Finally, if the conditions just described are not properly treated, or, as 
is more likely to be the case, if they are allowed to remain wholly untreated, 
the inflammation of the middle ear begins to encroach upon the neighbor- 
ing organs, and we then encounter, as results of this extension of the dis- 
ease, the following catalogue of lesions, which are often fatal : caries or ne- 
crosis of the bony walls of the middle ear or of the mastoid cells — the result, 
very commonly, of retained pus ; ulceration of the carotid artery, with fa- 
tal hemorrhage ; ulceration of the lateral sinus or of the communicating 
mastoid vein, with phlebitis, pyaemia, and perhaps metastatic abscesses ; 
meningitis, or abscess of the brain ; consumption, due to an infection of the 
system produced by a collection of cheesy pus and debris retained in the 
middle ear or mastoid antrum ; and perhaps still other lesions which do 
not now occur to my mind. 

For purposes of convenience, then, I will treat the subject of the pres- 
ent chapter under three headings, corresponding to the three groups into 

1 Not possessing the firm and healthy appearance of the normal mucous membrane. 






232 DIAGNOSIS AND TKEATMENT OP 

which I have divided all cases of chronic purulent inflammation of the mid- 
dle ear. Before considering these groups in detail, however, I will make a 
few 

General Remarks on Diagnosis and Prognosis. 

The term " chronic purulent inflammation of the middle ear," as already 
intimated, covers such a multitude of different conditions and combinations 
of conditions that, as diagnosticians, we must consider our task as only begun 
when we ascertain the fact that the case is one of otitis media purulenta chron- 
ica. It is not sufficient even to determine in a general way that it belongs to 
one of the three larger classes mentioned above. If we wish to treat the case 
successfully we must make a diagnosis of the exa rt condition of every square 
millimetre of the surface of the auditory canal, drum-membrane, tympanic 
mucous membrane, etc. — so far, at least, as it is possible to reach some of 
these remoter portions of the ear. As a matter of course there are parts 
which we cannot see, nor even reach with an instrument. When once, how- 
ever, the art of exploring the nooks and crannies of the middle ear has been 
learned, it is surprising how often we are rewarded by discoveries which ena- 
ble us to arrest the troublesome discharge, and perhaps also to relieve the 
patient of other distressing symptoms. The art of properly cleaning the ear 
is the art which I would urge the beginner in otology to cultivate. I am 
strongly tempted to add that when he has mastered this very difficult art, he 
will find himself a master, both in the diagnosis and in the treatment of dis- 
eases of the ear. This is not far from the truth. As an instructor I have re- 
peatedly made the observation that, after the ear had been properly cleansed, 
even a beginner would often be able to make a correct diagnosis of rather 
complicated conditions. But very rarely indeed have I known a pupil to be 
able to clean an ear even fairly well, until he had served a somewhat long ap- 
prenticeship. This cleansing process must be done by means of the cotton- 
holder, the curette, the slender middle-ear probe, and the delicate angular 
forceps. The syringe, as a rule, is not to be used. If the external audi- 
tory canal is filled with a very foul pus, it may be pleasanter for the physi- 
cian to remove as much of it as he can by syringing. If the discharge, 
however, is not particularly offensive, time will be saved by employing, from 
the very beginning, the cotton-holder armed with absorbent cotton. By 
varying the amount of cotton used, the physician can make a mop suitable 
either for the removal of large quantities of pus in the broad external audi- 
tory canal, or for the thorough cleansing of a small sinus leading through 
Shrapnell's membrane into the recesses of the middle ear. If syringing alone 
is employed, the picture afterward presented to the eye of the observer 
will almost invariably be a deceptive one. All the depressions and inter- 
stices will continue to hold a certain amount of water, and under these cir- 
cumstances the most experienced observer can scarcely fail to interpret 



DISEASES OF THE EAR. 233 

incorrectly what lie sees. But oftentimes even the cotton-holder fails to 
accomplish all that is desired. Masses of cheesy pus or of epithelium 
remain embedded in the recesses or cling firmly to the tissues, and we are 
obliged to use the curette, the slender probe, or the forceps. In all these 
recommendations I assume that I am dealing with physicians who possess 
a fair degree of steadiness of hand and delicacy of touch. I assume, fur- 
thermore, that they have mastered the art of illuminating the deeper parts 
of the ear with a forehead mirror. To men who are not accustomed to 
the delicate manipulation of instruments, this whole chapter must neces- 
sarily, in a large measure, prove unprofitable. If cases belonging to the 
first group come into their hands for treatment, they may, by employing 
the syringe and by instilling suitable remedial solutions into the ear, occa- 
sionally effect a cure ; but a large number of perfectly curable cases will 
experience comparatively little benefit from this — if I may be allowed the 
expression — indiscriminate firing at the enemy. It is far better, how- 
ever, for such men to recognize early their lack of manual dexterity, and 
to abstain religiously from using instruments of any kind in the ear. They 
will then be almost sure of doing their patients no harm, and they will, 
as already stated, occasionally effect a cure by those methods of treatment 
which necessitate the employment of no other instrument but the syringe. 

It is unnecessary to enter here into a minute description of the condi- 
tions which call for the use of this or that particular instrument, or to at- 
tempt a description of the proper modes of using them. I will simply for- 
mulate two general rules, which will be found, I believe, useful. In the 
first place, when granulation-tissue presents itself to view, it is never safe 
to assume that the relations are what they seem to be. Thus, for example, 
I have more than once thought, after thoroughly cleansing an ear, that the 
picture presented to my eye was one of a granulating and very much hy- 
pertrophied mucous membrane of the inner wall of the tympanum, with 
total destruction of the membrana tympani. By the aid of simple inspection 
this was as far as I was able to go in my interpretation of the appearances 
observed. By gently manipulating the parts with the probe or the curette, 
however, the incorrectness of my interpretation became at once apparent. 
The " granulating and hypertrophied mucous membrane of the inner wall 
of the tympanum " was in reality a flattened polypoid growth, lying upon 
the outer surface of the drum-membrane. Its peduncle, which passed 
through a large perforation in the posterior superior quadrant of the drum- 
membrane, sprang from the upper and posterior portion of the tympanic 
cavity. Long experience and the most careful scrutiny will never enable 
the physician to dispense with these instrumental manipulations. And it 
must be remembered that an error in diagnosis, under circumstances such 
as I have just described, means also an erroneous plan of treatment. 

The second rule to which I referred above, is this : it is a good plan to 
assume that, in the great majority of cases of long-standing otorrhcea, the 



234 DIAGNOSIS AND TREATMENT OF 

discharge is kept up either by a carious process in some portion of the tem- 
poral bone, or by a mass of granulation-tissue, situated in one of the fol- 
lowing three places : the external auditory canal, the middle ear proper, or 
the mastoid antrum. If the physician, therefore, expects to relieve his 
patient of his otorrhoea, he must ascertain, as accurately as possible, where 
the caries or the granulation-tissue is situated. It is not sufficient for him 
to ascertain, in a general way, that it is situated in the external auditory canal 
or in some part of the middle ear ; he must ascertain the precise limits of 
the disease, just as the general surgeon does in a case of caries of the tibia 
or in one of uterine polypoid growths. He must introduce his slender 
probe into every recess ; he must touch with it every spot of suspicious 
redness ; in a word, he must render to himself a strict account of every por- 
tion of the ear within his reach. If the external canal is free from granu- 
lation-tissue or from caries, and the pus clearly escapes from the middle 
ear through a perforation in the membrana tympani, he must pass his 
cotton-holder (armed with absorbent cotton) through the perforation and 
soak up the pus or mucus that fills the middle ear and prevents him from 
seeing the opposite promontory. In this way one can often bring to light 
a polypoid growth which otherwise would escape observation. But in 
many cases such a cleansing of the middle ear is not sufficient. The poly- 
pus may be so situated that no portion of it can be seen through the per- 
foration. For instance, it may spring from the upper or outer wall, and 
may hang down on one side or the other of the opening. In addition, 
therefore, to the cleansing, it is advisable to bend the end of the probe 
slightly, and then, passing it in through the perforation, to rotate it in such 
a manner that it will be likely to bring into the field of vision any polypoid 
growth that may be located in the immediate vicinity. If these manipula- 
tions are executed with delicacy — the surgeon's eye being directed all the 
time upon the perforation, and account being taken of the exact situation 
of the (concealed) end of the probe— the patient will probably not complain 
of even a sense of discomfort, much less of pain. If, after making a critical 
search, the physician fails to find either a caries or a region of granulation- 
tissue, he is still not warranted in drawing the inference that these lesions 
are absent, that is, that the case belongs to the first of the three groups 
into which I have divided all cases of otitis media purulenta chronica. He 
should proceed, however, to treat it as if it really did belong to this group, 
and upon the success or lack of success of his treatment he should finally 
base his diagnosis. I do not mean by this that his conclusion will always 
be in harmony with the facts ; but simply that there is a strong probability 
that such will be the case. In the absence of these lesions, a suitable medi- 
cation of the middle ear will soon arrest the discharge ; if these lesions, 
however, are present, the same medication will almost certainly fail to ac- 
complish this result. 
. So far as the question of prognosis is concerned, only a few rules of 



DISEASES OF THE EAK. 235 

general applicability can be laid down. In the first place, when a case of 
chronic purulent inflammation of the middle ear is brought to us for an 
opinion as to what is likely to be the future course of the disease, we must, 
in a large proportion of the cases, be guarded in our statements. This is 
true, in a special degree, with regard t,o the effects of treatment. Let us 
consider, first, the question of the arrest of the discharge, which is generally 
the one that most interests the patient. Taking a large number of cases 
together, we may promise very good results from treatment, but in indi- 
vidual cases we cannot safely predict what will be the results. Oftentimes 
the cases winch seem as if they would be the easiest to manage, and with 
regard to which we feel disposed to give a very favorable prognosis, prove 
in the end to be the most stubborn. On the other hand, if the discharge 
is profuse and offensive, and if there is an abundant development of granu- 
lation-tissue, we may safely make the prediction that treatment will effect 
a very marked improvement in the condition of the ear, — that the discharge 
will be greatly diminished in quantity, and at the same time be rendered 
inoffensive. In fact, in quite a large number of cases the discharge will be 
arrested permanently, but it is not safe to predict such a result. The prog- 
nosis is perhaps better in cases in which the perforation in the drum-mem- 
brane is large than in those in which it is small. In the next place, the 
prognosis is far better in cases in which the perforation involves the niein- 
brana tympani proper than in those in which the discharge escapes through 
an opening in Shrapnell's membrane or in the soft parts in that immediate 
vicinity. 

The next question in prognosis to which we must frequently give an 
answer, relates to the recovery of the hearing-poiuer in the ear affected. If 
masses of granulation-tissue surround, and perhaps even press upon, the 
stirrup, and if we find that we can remove these masses, we may safely say 
that a certain degree of improvement in the hearing will be likely to result 
from treatment. The effects produced by the presence of a purulent or 
muco-purulent fluid in the middle ear upon the acuteness of the hearing 
is very nearly the same as those due to a mass of granulation-tissue, when 
the latter occupies the position just mentioned. It would appear, there- 
fore, as if, in those cases in which there are no obstructive granulations, 
our prognosis should be the same with regard to the improvement of the 
hearing as with regard to the arrest of the discharge. This is true in per- 
haps the majority of cases. In a certain proportion of the cases, however, 
the hearing seems to be affected by other changes, directly dependent upon 
the arrest of the discharge. Thus, for example, after we have succeeded in 
arresting the discharge, the patient will be conscious for a short time that 
his hearing is better than it was during the continuance of the discharge. 
Then gradually the hearing will become less acute and the patient will 
complain that he does not hear as well as when the discharge existed. If 
some slight exposure causes the otorrhcea to return, we may observe the 



236 DIAGNOSIS AND TREATMENT OF 

apparently perplexing phenomenon of an increased acuteness in the hear- 
ing power, due to the re-establishment of a purulent otitis media. The ex- 
planation of these conflicting phenomena, which are encountered by no 
means rarely, is undoubtedly the following : So long as the soft parts sur- 
rounding the stirrup, and especially its foot-plate, are moist, this ossicle 
possesses its highest degree of mobility. For a short time after the dis- 
charge has been arrested these soft parts remain simply moist, and, in the 
absence of any considerable quantity of free fluid, which would of course 
act as a damper, the stirrup can vibrate with the maximum degree of free- 
dom — that is, the patient's hearing will be at its maximum degree of acute- 
ness. With the increasing dryness of these parts, however, they lose their 
flexibility, and the stirrup, or rather the stapedio-vestibular articulation, 
then becomes partially anchylosed, and the patient's hearing will then be at 
its minimum degree of acuteness — a lower degree even than that which 
existed when the middle ear was filled with fluid. 

Finally, we are sometimes called upon to state how far a chronic puru- 
lent inflammation of the middle ear is likely to endanger the patient's life. 
If we are asked the question in a general way, as for instance by the officers 
of a life insurance company, we can only say that a small proportion of all 
the individuals who are affected with a chronic discharge from the ear die 
from some form of disease directly induced by the ear affection. * If we are 
asked, on the other hand, to state the probabilities in individual cases, we 
must base our predictions upon a variety of data, viz., the past history of 



1 The practical question which presents itself to the life insurance authorities is 
this : Should a sweeping rule be laid down to the effect that all applicants who may 
be affected with a chronic discharge from the ear, must be rejected? Or should 
these cases be investigated, and the decision made to depend upon the result of the 
investigation ? The sweeping rule affords undoubtedly the safest and simplest way 
out of the difficulty. Ab the same time such a course would lead to the rejection of 
many good risks, which rival companies would be quick to accept. On the other hand, 
if the attempt were made to discriminate carefully between the comparatively safe 
and the more dangerous cases of otorrhcea, the services of an expert would have to 
be secured, and to this additional expense the great majority of life insurance offices 
would object very seriously. In the next place, such expert examinations could only 
be obtained in the cities. This alone, therefore, would render the adoption of such a 
rule impracticable. I think, however, that if favorable answers can be obtained to 
questions bearing upon a few of the more important points, these cases of otorrhcea 
may be accepted as fair average risks. The points to which I have reference are 
these : duration of the discharge — whether constant or intermittent ; its characteris- 
tics — whether thick or watery in its nature, whether odorless or offensive, and whether 
tinged with blood at times or simply purulent ; the frequent occurrence of pain in the 
ear or in any part of the head; and, finally, the existence of tenderness on pressure 
behind, above, or in front of the ear. On the other hand, if the applicant states that 
the discharge is abundant, that it is offensive, that it is occasionally bloody, and that 
he is subject to pain in the region of the affected ear or throughout that side of the 
head, the risk should certainly be considered as extra-hazardous. 



DISEASES OF THE EAR. 237 

the case, the nature of the existing lesions, the care which is likely to be 
bestowed upon the diseased ear, etc. Frequent intercurrent acute attacks 
of inflammation in the past afford some indication of what may be expected 
in the future. If a large perforation exists in the drum-membrane, and the 
external auditory canal is of normal size, we may estimate lightly the dan- 
ger of either mastoid or cerebral disease. A small perforation in the drum- 
membrane proper involves far less risk of serious intercurrent disease than 
does one in the region of Shrapnell's membrane. When the existence of 
a carious process can be demonstrated in or near the tympanic cavity, the 
patient should be warned of the serious nature of his disease, and he should 
be urged to keep the ear scrupulously clean, and to obtain skilled assistance 
with the least possible delay when pain develops in or near the ear. Far- 
ther on I may recur to this subject of prognosis again. 



Different Types of Chronic Purulent Inflammation of the Middle Ear. 
I. Simple Uncomplicated Cases. 

Strange as it may seem, the number of cases that belong strictly to this 
first group is by no means so large as one might suppose. It is quite 
possible that the absolute number of such cases is large ; but, as the symp- 
toms are not of a troublesome nature, many patients probably think it un- 
necessary to consult a physician, and so it happens that the aurist sees only 
a few of them. The only difference that exists between these cases and 
those of subacute catarrhal inflammation of the middle ear is, I suspect, 
the following : in the former group the absence of the whole or a part of 
the membrana tympani leads to the establishment of a more active secre- 
tion from the mucous membrane of the middle ear than is apt to be the 
case when the drum-membrane is entire. The exciting cause is probably 
the same in both sets of cases ; it is only in the outward manifestations of 
these diseases, but not in their intrinsic nature, that a difference exists be- 
tween the two. The term employed by many English and German writ- 
ers to designate the purulent form of the disease, — viz., "purulent catarrh 
of the middle ear," — is one which seems to be peculiarly appropriate to 
this class of cases. At the same time there are decided objections to the 
employment of the term " catarrhal " in this connection (see p. 142). The 
chief distinguishing feature of these simple uncomplicated cases of chronic 
purulent inflammab' n of the middle ear is the total absence — so far, at 
least, as can be ascertained from the character of the discharge and from 
the visible and tangible lesions — of any evidences of active inflammation, or 
of the development of granulation-tissue. 

The following case may be taken as a type of the form of disease now 
under consideration : The patient, a lady, forty years of age, stated that 



238 DIAGNOSIS AND TREATMENT OF 

she had passed through a rather severe attack of purulent inflammation of 
both ears when she was quite a young girl. She believed that the attack 
had begun while she was convalescing from scarlet fever. From that time 
forward she had been subject to an intermittent discharge from both ears, 
never copious nor offensive, and, so far as she had observed, never materi- 
ally affecting her hearing. On examination (April 6, 1871), I found both 
drum-membranes perforated, the opening in each being of large size. A 
very slight quantity of thin secretion moistened the lower wall of the exter- 
nal auditory canal. The mucous membrane of the promontory was pale, 
moist, and moderately thickened. At no point was there any evidence of 
active irritation. No treatment was advised beyond the occasional cleans- 
ing of both ears with a little lukewarm water. Four years later (June 8, 
1875) I again saw the patient. She reported that no change had taken 
place in the course of the disease ; and, on examination, I found almost 
precisely the same picture as that which I had observed in 1871. On the 
left side it seemed to me that the perforation had materially increased in 
size ; of this change, however, I could not feel positive. 

In cases like the one which I have just narrated it would undoubtedly 
be easy to control the slight discharge for a limited period by instilling 
into the middle car a feebly astringent solution, say one of nitrate of silver 
(gr. ij. ad § j.) ; but in these typically chronic cases we cannot look for 
permanently beneficial results, and it is therefore better not to urge the 
patient to submit to treatment. In cases of more recent origin, and espe- 
cially in those which are characterized by a small perforation in the drum- 
membrane, treatment is more likely to produce results which will be per- 
manent and which the patient cannot fail to appreciate. The following 
case may serve as an illustration : The patient, a merchant, forty years of 
age and in good health, first noticed a discharge from the left ear during 
the second week of August, 1878. It came on without pain, and contin- 
ued unchecked up to the 13th of September. On examination made at 
that time, the external auditory canal was found to be filled with a moder- 
ately thick, purulent fluid. A perforation about the size of a pin's head, 
and with sharply defined limits, occupied the central portion of the drum- 
membrane, which otherwise appeared to be natural, or at least free from 
any evidences of inflammation. After the middle ear had been inflated 
(Politzer's method), for the purpose of driving out as much of the secretion 
as possible, a few drops of a ten-grain solution of nitrate of silver were 
dropped into the left ear, firm pressure was then mi le upon the tragus, 
and at the same time the patient was told to perform the act of swallowing 
three or four times in succession. In this way the remedial solution was 
brought in contact with probably a large part of the tympanic mucous 
membrane. No appreciable pain followed this procedure. 

On the 16th of September the patient reported that the discharge 



DISEASES OF THE EAE. 239 

ceased on the fourteenth, and that the ear since then had felt quite natural 
On examination, both the external auditory canal and the tympanic cavity 
were found to be perfectly dry ; the perforation still persisted. 

There can be very little doubt that the perforation in this case was the 
result of some former attack of inflammation of the middle ear, and not of 
the painless attack which I have just described. In the next place, the 
proinp h manner in which the tympanic mucous membrane returned to a 
healthy condition and remained so for many months afterward (I have met 
the patient frequently since 1878), shows conclusively that the case belongs 
strictly in this first class of uncomplicated cases. Finally, there is still 
another point of practical importance which is suggested by this case. The 
method which I employed of introducing the remedial solution into the 
middle ear is a rather crude but useful method of accomplishing the de- 
sired purpose, provided the perforation in the drum-membrane is suffi- 
ciently large (i.e., not much smaller than the head of an ordinary pin). If 
the perforation, however, is quite small, the middle-ear pipette will be 
found to afford the only sure means of introducing fluids into the tympanic 
cavity. As this subject of medication of the middle ear is one of great 
practical importance, I make no apology for giving below, in brief outlines, 
the histories of three cases in which the successful results obtained were 
largely due, I believe, to the employment of this more direct method of 
introducing remedies into the tympanic cavity. 

Case I. — The patient, a clerk, about thirty-five years of age and in good 
general health, was brought to me by his physician on the twentieth day 
of October, 1879. The story which he gave of his ear trouble was this : 
About the first of October he was struck on the left side of the head, and 
for nearby a week afterward he experienced severe pain in the left ear. On 
or about the fourth day he discovered that matter was escaping from the 
left auditory canal, and from that time forward the discharge had been 
constant. On examination, I found the left external meatus filled with a 
thick, purulent fluid. A perfectly circular perforation occupied the posterior 
inferior quadrant. It presented no resemblance whatever to a perforation 
of traumatic origin, i.e., due to the violent concussion of the air in the mea- 
tus. In all other parts the membrana tympani presented a very whitish and 
tough appearance. The impression made upon my mind was that at some 
earlier period of his life the patient had been subject for a long time to 
a purulent inflammation of the left middle ear, and that both the perfora- 
tion and the marked hypertrophy were the results of that earlier inflamma- 
tion ; while the blow which he had recently received had merely brought 
on a somewhat severe otitis media purulenta acuta. From the patient, 
however, I was unable to obtain any evidence corroborative of this view. 



240 DIAGNOSIS AND TKEATMENT OF 

He was positive that the ear had always been perfectly healthy before he 
had received the blow. 

I advised the attending physician to instil (three times a week) a five- 
grain solution of nitrate of silver into the external meatus, after he had 
thoroughly removed all the pus, and then to force it through the perfora- 
tion into the middle ear in the manner described above. I then performed 
the operation once in his presence, in order that he might see exactly how 
the treatment was to be carried out. 

On the 9th of November the physician brought his patient to e 3e me a 
second time. He reported that the discharge had increased rather than 
diminished. On questioning the patient I ascertained that he had not once 
tasted the silver solution since the day on which I first saw him ; in other 
words, it is fair to assume that the remedial solution had only on that occa- 
sion been successfully brought in contact with the tympanic mucous mem- 
brane. This plan of treatment having failed, I resorted to the use of the 
pipette, and introduced two or three drops of a ten-grain solution of ni- 
trate of silver into the tympanic cavity. The patient felt it in his naso- 
pharyngeal space almost instantly. He also experienced quite a sharp ear- 
ache, which was relieved in about one minute by pouring rather hot water 
into the upturned meatus. 

On the 11th and 13th of November the remedy was again introduced 
into the middle ear in the same manner, and on the 15th the patient re- 
ported that there had been no discharge during the previous forty-eight 
hours. Inspection of the parts also showed that the discharge had entirely 
ceased, and that even the tympanic cavity was free from unnatural secretion. 

On the 9th of January, 1880, the patient consulted me again. He stated 
that about five days after I last saw him the discharge had reappeared, and 
had been constant since that time. He had been too much occupied with 
his business affairs, however, to place himself again under medical care. 
The same plan of treatment (with the pipette) was resumed. 

January 11th. — Discharge still active. Silver solution introduced a 
second time. 

January 14th. — No improvement perceptible. The thought then oc- 
curred to me that my lack of success was probably due to the fact that the 
remedial solution did not come in contact with more than a comparatively 
small portion of the tympanic mucous membrane, owing partly to the im- 
perfect manner in which I cleansed the cavity of the middle ear, and partly 
to the small quantity of the remedial solution injected. I accordingly 
syringed out the tympanum with Blake's middle-ear syringe, using the 
entire contents of a full syringe (a little over one drachm) for that jyurpose. 
So far as I could discover, this procedure brought away only a little ropy 
mucus. I then injected into the middle ear two or three drops of a ten- 
grain solution of nitrate of silver, and, after the lapse of a few minutes, no 
pain having developed in the meantime, I repeated the operation, each 



DISEASES OF THE EAE. 241 

time causing the solution to pass through the Eustachian tube into the 
naso-pharynx. 

The patient returned on the 17th of January and reported that the dis- 
charge had entirely ceased. Inspection also confirmed this statement. Be- 
fore dismissing the patient, however, I introduced into the left tympanic 
cavity, by means of the slender middle-ear probe, two or three pellets of 
powdered iodoform and burned alum, in about equal parts. About six 
weeks later he reported that up to that time no relapse had occurred. 

Case II. — The patient, a man forty years of age and in good general 
health, stated that in boyhood he passed through an attack of scarlet fever, 
which left him with both ears damaged. At long intervals he had had a dis- 
charge from the right ear, and recently he had also noticed a sense of ful- 
ness in the left ear, and at times a slight watery discharge from it. On 
examination (December 27, 1879), I found the left meatus moistened with 
a thin, watery discharge, and the membrana tympani somewhat bulging and 
decidedly soaked in appearance. No perforation was visible, but probably 
a small, valve-like opening existed in the posterior half of the membrane. 
When Valsalva's experiment was performed by the patient, the membrana 
tympani yielded as a whole to the pressure from within, but there was no 
escape of fluid to indicate the location of the perforation. I might state 
here that sometimes, in acute cases, the transudation of fluid through the 
unbroken membrana tympani is so active as to produce not merely a moist 
condition of the auditory canal, but even a discharge from the external ori- 
fice. It is quite possible that such a state of things existed in the present 
case. At the same time it is not safe to infer that no perforation exists 
simply because we are unable to discover one. A small mass of mucus 
may effectually plug the opening for a short time, or its edges may become 
glued together temporarily. The existence or non-existence of a perfora- 
tion, however, was not in this instance a matter of any importance, as it 
was very evident that the perforation — if it really existed — was too small 
to be of much service as an outlet. I therefore made a free incision through 
the bulging posterior half of the membrane, and afforded escape to some 
pinkish serum. Although the pressure had been withdrawn, the posterior 
half of the membrane retained its convex condition, showing clearly that 
the pressure from within must have been of comparatively long standing. 
Without any prelimiiiaiy washing-out procedures, I introduced, with the 
pipette, two or three drops of a two-grain solution of nitrate of silver into 
the middle ear. No unpleasant symptoms followed. 

On the 28th of December, the discharge still continuing, and the open- 
ing in the membrane still being of ample size, I introduced a five-grain so- 
lution into the tympanic cavity. None of it appeared to reach the naso- 
pharynx in the ordinary manner ; but yet, almost instantly after the injec- 
tion had been made, tears began to flow freely from the patient's left eye, 
16 



242 DIAGNOSIS AND TKEATMENT OF 

and, for perhaps two or three minutes, he experienced quite a sharp pain 
in the ear. 

On the 30th of December, patient reported that the discharge had di- 
minished in quantity and that the ear felt lighter (i.e., less full). On ex- 
amination I found that the lower wall of the meatus was barely moist, and 
that the posterior half of the drum-membrane had almost entirely lost its 
unnatural convexity. The perforation had nearly healed. After clearing- 
out the middle ear by means of Politzer's method of inflation, I injected 
into the tympanum, by means of the pipette, a much larger quantity of 
the silver solution (five grains to the ounce) than I had ever injected 
before. It amounted to at least ten drops, and as the perforation was 
then quite small, no regurgitation took place, as on the previous occasion. 
Tears at once came into the left eye, and for some minutes the patient was 
unable to utter a word, so much of the solution had escaped into his 
throat. A watery fluid ran for a short time in an almost continuous stream 
from the left nasal orifice. The pain in the ear was quite sharp, but it 
yielded very quickly to instillations of hot water. 

On the 2d of January, I found that the discharge from the ear had al- 
most ceased. As there seemed to be no free fluid in the middle ear, I 
forced through the perforation, into the tympanic cavity, a few small pellets 
of powdered iodoform and burned alum. 

January 4th. — Same condition. Iodoform and alum introduced a sec- 
ond time. 

On the 8th of January the patient reported that the discharge had not 
reappeared since the 4th insi On inspection I found the membrana tym- 
pani pale, dry, and of perfectly natural curvature. A small scab covered 
the site of the perforation. The hearing distance, for the watch, had in- 
creased from two inches up to nine inches. So far as conversation was 
concerned, the patient experienced no difficulty whatever in hearing all 
that was said to him. (On the right side, I should have stated before, the 
drum-membrane was amalgamated with the tissues of the promontory.) 

Case HE. — The patient, a college student, seventeen years of age and 
of good physique, consulted me on the 16th of September, 1878, on ac- 
count of a discharge from both ears, associated at times with pain. So far 
as he could remember, the discharge began during his childhood, and had 
continued without intermission up to that time. On one or two occasions 
he had found the secretion slightly stained with blood. Furthermore, the 
discharge varied in activity, at times being barely perceptible. During 
the period immediately preceding his visit, however, it had been more pro- 
fuse than usual. On examination I found both auditory canals filled with 
thick muco-pus. Both drum-membranes presented the same lesions, viz., 
a small, round perforation in the posterior inferior quadrant, marked bulg- 
ing of the posterior half, a generally tough and soaked appearance of the 



DISEASES OF THE EAR. 243 

whole membrane, and, finally, entire absence of any evidence of active irri- 
tation. The most urgent indication on both sides, therefore, was to establish 
a free outlet, and thus to relieve the constant condition of pressure upon 
the mucous membrane of the middle ear and the constant partial stagna- 
tion of the purulent secretion. I therefore made a long, crescent-shaped 
incision in the posterior half of each drum-membrane, and, after removing 
as much of the fluid contents of the middle ear as I could, I injected several 
drops of a ten-grain solution of nitrate of silver. 

On the following day, the 17th, the patient reported that the discharge 
had diminished noticeably in quantity, especially on the left side. He had 
also experienced no pain since the operation. (And here I might state 
that, if the precaution be taken to establish an opening of ample size in 
the membrana tympani, before we inject our remedial solution into the 
middle ear, we need feel no fear that a prolonged painful reaction will fol- 
low this procedure. If the perforation, however, is quite small, my rule is, 
not to inject a solution of nitrate of silver of greater strength than two 
grains to the ounce of water.) On inspection I found that the edges of 
the wound, in both drum-membranes, were somewhat red and swollen. 
No injections made. 

On the 18th I repeated the injections, using on both sides a forty-five 
grain solution of nitrate of silver. Very little pain followed. 

On the 19th I found that the discharge was very trifling. I therefore 
pushed a few pellets of powdered iodoform (-^) and burned alum (§-) 
through the perforation into the tympanic cavity. 

On the 20th I repeated this procedure. 

On the 23d the patient reported that he had been entirely free from 
discharge since the 20th, and on examination I found the parts almost 
perfectly dry. As the patient was anxious to return that day to his home 
in Michigan, I was unable to keep the case any longer under observation. 
I have very little doubt, however, that what was then an apparent cure 
proved to be a permanent one. 

To these three histories I might add a fourth, which illustrates a some- 
what different method of treatment. The patient, a child, six years of age, 
had been subject since infancy to a slight watery discharge from the left 
ear, the result of an attack of measles. On examination (Oct. 11, 1876) I 
found a moderate amount of thin, purulent secretion in the left meatus. 
The membrana tympani showed no evidences of active inflammation, but 
a small circular perforation occupied the anterior inferior quadrant. After 
drying the parts as thoroughly as I could, I introduced the end of the mid- 
dle-ear probe, on which a bead of nitrate of silver had been fused, into 
the middle ear through the perforation. I pressed it for an instant against 
the mucous membrane near the orifice of the Eustachian tube, and then 
quickly withdrew it. The child made no complaint of pain afterward. 



244 DIAGNOSIS AND TREATMENT OF 

On the 14th of October the mother reported that no discharge had 
been seen since the 11th, and that the child's hearing had appreciably im- 
proved. Inspection showed the parts to be perfectly dry. 

The objection to this latter plan of treatment, in the simple uncompli- 
cated cases of otitis media purulenta chronica, is this : if we allow the bead 
to remain in contact with the tympanic mucous membrane for too long a 
time, we may subject the patient to unnecessary pain. Taking all things 
into consideration, I have no hesitation in asserting that nitrate of silver in 
the form of a weak solution (from two to five grains to the ounce of water), 
if brought thoroughly in contact with the mucous membrane of the middle 
ear, constitutes the most efficient and most easily managed remedy that we 
possess for the treatment of these uncomplicated cases of chronic purulent 
inflammation of the middle ear. 

Cheesy inflammation of the middle ear. — In certain oases the establish- 
ment of a purulent inflammation of the middle ear takes place in such a 
painless, insidious manner that one cannot avoid the suspicion that the 
process is related in some manner to that which often takes place in the 
lungs, in the cervical lymphatic glands, and in other parts of the body. 
The suspicion ripens into belief when we find other evidences that the in- 
dividual is affected with tuberculosis. In these cases, furthermore, treat- 
ment seems to be of very little effect : the parts display no tendency what- 
ever toward reparative action, and in some cases a curious process develops 
without any adequate provoking cause. In one or two cases I have noticed 
what I might term an unduly rapid melting away of the edges of the per- 
foration, such as is sometimes observed in a purulent otitis media following 
scarlet fever. Beyond these ill-defined symptoms I have never observed 
anything, in these apparently tubercular cases, which might fairly be called 
diagnostic of the disease. The form of inflammation, however, which is 
called cheesy inflammation * of the middle ear, presents a very striking pic- 
ture ; one so totally different from that observed in any of the other forms 
of middle-ear disease encountered in healthy (non-tubercular or non-con- 
sumptive) individuals, that one is strongly tempted to consider it as char- 
acteristic of a tubercular form of middle-ear disease. The following cases 
are the only examples of cheesy inflammation of the middle ear that I have 
ever seen : 

Case I. — The patient, a man thirty-two years of age and in a poor gen- 
eral condition (habitual cough, night-sweats, incurvated nails, emaciated 
countenance), gave the following account of his ear affection : About one year 

1 See Schwartze's Pathological Anatomy of the Ear, translated by J. Orne Green. 
Houghton, Osgood & Co. , Boston. 



DISEASES OE THE EAR. 245 

previously lie had experienced slight pain in one ear, which was followed 
shortly afterward by a discharge. In the course of six months he went 
through the same experience with the other ear. In both ears the dis- 
charge lasted only for a short time, but the deafness, which was well- 
marked, had continued unchanged ever since. On examination, October 
4, 1876, I found the right drum-membrane of a peculiar pale, flesh-tint 
color, with two or three dilated blood-vessels crossing its outer surface. 
The impression conveyed to the eye was as if the drum-membrane had been 
stretched so tightly over some whitish body that its superficial blood-ves- 
sels (veins) had been compelled to perform not only their own legitimate 
task, but also that of the more deeply situated, but then obliterated vessels. 
I saw this case only once. I made a note of the conditions observed, 
but was not able at that time to offer any satisfactory explanation of their 
origin or significance. I also omitted to test the membrane with the probe ; 
though the appearances were such that I could scarcely have been mistaken 
with regard to the presence of some send-solid material in the tympanum, 
which pressed sufficiently against the drum-membrane to interfere with 
the circulation on its mucous surface. In the light of the following case, 
however, I believe that the two cases were essentially identical. 

Case II. — The patient, a clerk, about thirty years of age and in rather 
poor general health, and with all the external appearances of a person af- 
fected with phthisis, consulted me on the 30th of January, 1878, for marked 
deafness affecting both ears. He gave the following account of his trouble : 
During the previous autumn, as a result of sea-bathing, both ears had be- 
gun to discharge. He was very positive that the affection had developed 
without pain, and that previous to that time his hearing had been perfect. 
In corroboration of this statement he called my attention to the fact that 
he was the head of one of the departments in a large publishing house, and 
that it would scarcely have been possible for him to have risen to that posi- 
tion, and to have performed its duties properly, unless his hearing had been 
fairly good. At the time when I saw him his deafness was so marked that 
I was obliged to speak in quite a loud tone of voice in order to make my- 
self understood. On examination, I found the right auditory canal per- 
fectly dry. The drum-membrane presented a peculiar whitish, polished 
appearance. A circular perforation, with sharply cut, somewhat thickened 
edges, occupied the anterior superior quadrant. The entire posterior half 
of the membrane was in a perceptibly bulging condition and over its sur- 
face ran two or three dilated and sharply defined blood-vessels. When I 
tested this bulging portion with the probe I found that the drum-mem- 
brane was resting upon some solid substance. It felt more like a semi- 
solid substance (cheesy material, for example) than like bone. Anteriorly 
the drum-membrane yielded readily to the pressure of the probe. On the 
left side, I found a little thin, purulent secretion in the auditory canal. The 



246 DIAGNOSIS AND TKEATMENT OF 

drum-membrane was in all essential respects like the right one. The only 
difference that I could discover was this : the perforation was slit-shaped 
and occupied the anterior inferior quadrant, close to the periphery of the 
membrane ; whereas in the other ear it was circular and occupied the an- 
terior superior quadrant, midway between the periphery and the handle of 
the hammer. 

I expressed to the patient's physician the belief that cheesy material had 
accumulated in both middle ears, and said that I would like to make an in- 
cision through the bulging posterior half of one drum-membrane and en- 
deavor to wash out the cheesy material ; and if the operation proved suc- 
cessful, I should want to repeat it on the other ear. My proposition was 
explained to the patient, but he declined to submit to any such operative 
interference. 

II. Proliferative Cases. 

As the cases belonging to this second group are almost invariably char- 
acterized by either an abundant or an offensive discharge, — two symptoms 
which are annoying to the patient and which therefore lead him to seek 
relief, — they will be found to constitute, I think, the larger part of all the 
cases of otitis media purulenta chronica which come under the aurist's ob- 
servation. The feature which distinguishes them from the cases that be- 
long to the preceding class, consists in the proliferative tendency displayed 
by the inflamed mucous membrane. This proliferative process affords un- 
mistakable evidence that the mucous membrane is being subjected to some 
unusual irritating influence. There are two ways,in which we can account 
for the existence of such an irritating influence. In the first place, decom- 
position may take place in the secretion and impart to it properties which 
are in the highest degree irritating. Under the influence of this irritation 
the mucous membrane begins to proliferate at one or more points, and so 
granulation-tissue, or a distinct polypoid growth representing an enormous 
hypertrophy of all the normal structures of the tympanic mucous mem- 
brane, may be developed. In other cases, however, the irritating influence 
may emanate from an entirely different source. Thus, for example, pro- 
longed pressure, during the original acute attack, may have deprived the 
superficial portion of the bony wall of the tympanum, over a limited area, of 
its nourishing supply of blood, and thus have produced death both of the 
bone and of the mucous membrane immediately covering it. Such a caries of 
the bony wall of the tympanum supplies a secretion of a very irritating charac- 
ter, and, under the constant stimulus of this irritant, masses of granulation- 
tissue are formed in precisely the same manner as they are formed at the 
orifice of a sinus leading from the surface of the body to a spot of carious 
bone. When, therefore, we find granulation-tissue or polypoid growths in 
the middle ear or external auditory canal, we may feel perfectly sure that 



DISEASES OF THE EAR. 247 

a discharge of an irritating nature bathes these parts. Here, then, is fur- 
nished the first and most important indication of what is required in the 
way of treatment, viz., that in all cases belonging to this second class we 
should adopt every means at our command to keep each nook and corner of 
the middle ear and external auditory canal clean. If the irritating secretion 
owes its peculiar properties simply to the decomposition which always takes 
place in a stagnating animal secretion, systematic and thorough cleansing 
will often of itself, without other measures, produce the desired cure. If 
the irritating secretion, however, comes from a superficial bone-caries we 
can scarcely expect simple cleansing measures to produce as prompt and 
satisfactory results as in the proliferative cases which are not dependent on 
bone-caries. 

Granulation-tissue may develop at any point in the cavities of the mid- 
dle ear. Growths of this kind are found more rarely in the vicinity of 
the orifice of the Eustachian tube than in any other part of the tympanic 
cavity. Speaking again simply from memory, I should say that they de- 
velop more often at the posterior and upper portion of the tympanic cavity 
than at any other point. So far as their texture and size are concerned, 
they differ widely. Some are extremely vascular, while others are but 
poorly supplied with blood-vessels ; some have almost the soft consistency 
of a myxoma, while others are as hard as the hardest fibroid growths ; some 
are as small as the head of a pin, while aural polypi very commonly reach 
the size of a bean. I have one in my collection which measures an inch 
and three-fourths in length, and fully half an inch in diameter at its 
broadest point. It is not an uncommon experience to find the larger 
growths lobulated or branching. 

So far as my experience goes, the great majority of polypoid growths 
encountered in the external auditory canal are of middle-ear origin. Fur- 
thermore, even the largest of these large polypoid growths will be found, 
as a rule, to possess remarkably small peduncles. 

It would almost require a separate treatise to describe thoroughly the 
different pathological pictures that are presented by these proliferative 
cases of chronic purulent inflammation of the middle ear. Furthermore, 
the value of such an exhaustive description would be small in comparison 
with the labor that it would entail. I will describe, therefore, only a few 
instances of this proliferative variety. 

Case I. — The patient, a strong, healthy boy, seven years of age, was 
brought to me by his mother on the 3d of October, 1872. She stated that 
he had had a constant discharge from the right ear since early infancy. On 
examination, I found the meatus partially filled with pus. The membrana 
tympani had been totally destroyed. All that remained of the handle of 
the hammer was a mere stump, which projected into the cavity of the tym- 
panum. The mucous membrane covering the promontory was much hy- 



248 DIAGNOSIS AND TREATMENT OF 

pertrophied, and at two or three points it presented small knobs of granu- 
lation-tissue. From the posterior and upper portion of the tympanic cavity 
a polypoid growth sprang. It was of moderate size, and its peduncle was 
comparatively small. By means of Blake's snare I removed this growth 
without any difficulty. To the stump and to the remaining smaller knobs 
on the promontory I applied powdered burned alum. My instructions to 
the mother were that she was not to syringe the ear with lukewarm water 
until the discharge reappeared, — my object being to keep the alum in con- 
tact with the granulating surfaces as long as possible. 

Failing to arrest the discharge entirely by means of these applications 
of powdered burned alum, on the 15th of October I applied the liquor ferri 
subsulphatis, on a small pledget of cotton, to the base of the polypoid 
growth, and touched the granulating spots on the promontory in the same 
manner with a forty-five-grain solution of nitrate of silver. 

On the 21st of October I applied powdered burned alum again, the 
discharge having in the meantime almost ceased. 

On the 24th of October I found the parts perfectly dry and quite nat- 
ural in appearance. 

On the 19th of January, 1880, more than seven years later, I had an 
opportunity of examining the ear again. To my great surprise the drum- 
membrane had been almost entirely reproduced. Posteriorly and supe- 
riorly a small gap still remained, but everywhere else a very thin and very 
much depressed membrane separated the cavity of the tympanum from that 
of the external meatus. (See remarks on p. 273, with reference to the re- 
production of the membrana tympani.) 

Case II. — The patient, a girl eight years of age, had been affected with 
a discharge from the left ear since early infancy, the discharge at times 
being stained with blood. On examination, October 29, 1873, I found the 
canal ulcerated, very much narrowed, especially in its deeper portion near 
the drum-membrane, and bathed with a rusty-colored secretion. The con- 
dition of the membrana tympani and middle ear could, at that time at least, 
only be inferred from the history of the case, and from the fact that during 
inflation air escaped freely from the external auditory canal. The slightest 
touch with the mop of cotton caused the ulcerated walls of the meatus to 
bleed. The treatment adopted was the following : at the Infirmary I 
cleansed and dried the canal as thoroughly as possible, and then applied 
nitrate of silver to the entire surface — the first time, a forty-five grain solu- 
tion ; on the 5th of November, the pure salt, in the form of a bead fused on 
the end of the cotton-holder ; at her home the patient's ear was syringed 
regularly three or four times a day with lukewarm water. Under this plan 
of treatment the discharge — which undoubtedly came in large measure from 
the ulcerated walls of the meatus — diminished greatly in quantity and as- 
sumed the character of a moderately thick purulent secretion, free from 



DISEASES OF THE EAR. 249 

any admixture of blood. The swelling of the canal so far subsided that 
on the 8th of November I was able to make out the exact condition of the 
middle ear. The drum-membrane had been entirely destroyed. Two 
polypoid growths, having rather large peduncles, sprang from the posterior 
end of the tympanic cavity. Both of these were removed with the snare. 

On the 19th and 26th of November I applied nitrate of silver to the 
bases of the growths recently removed, as they showed a strong disposition 
to grow again. 

On the 29th I used the snare for the purpose of cutting down the knobs 
of granulation-tissue — the bases of the former polypoid growths — as nearly 
as possible to the level of the surrounding mucous membrane. I then 
touched the remaining raw surfaces lightly with chromic acid. 

On the 3d of December I found the region which I had recently burned 
with chromic acid almost on a level with the surrounding mucous mem- 
brane. The discharge, too, had almost ceased. I accordingly applied 
powdered iodoform to the parts, and gave instructions that the syringing 
was to be discontinued. 

On the 6th of December, the discharge having ceased and the parts ap- 
pearing to be perfectly free from active irritation, I dismissed the case as 
no longer requiring treatment. 



In the preceding case I would call especial attention to the swollen and 
ulcerated condition of the cutaneous walls of the external auditory canal. 
In infirmary practice this is not an uncommon lesion in cases of chronic 
purulent inflammation of the middle ear. It shows clearly that no attempts 
whatever have been made to keep the ear clean, or else that these efforts 
have not been skilfully conducted. In such cases our first attention should 
be directed to the restoration of the meatus to a healthy condition. Fre- 
quent and thorough douching or syringing of the ear at home, and the oc- 
casional application of nitrate of silver (pure, in the form of a bead) to the 
greater part of the swollen and ulcerated surface, by the physician, are the 
two things that will most rapidly restore the parts to a healthy state. When 
this has been accomplished, the treatment of the diseased middle ear can 
be undertaken intelligently and with good prospect of a successful issue. 

I might mention here that in cases of chronic otorrhcea, living maggots, 
the larvae of the ordinary house-fly, are occasionally found in the meatus 
or even in the tympanic cavity. I have only once or twice encountered 
them in the ear, but they have been seen more frequently by Gruber, 1 
Blake, 2 and others. The explanation usually given is this : the fly, attracted 
by the offensive odor of the discharge, deposits her eggs in the meatus near 



1 Monatsschrift fur Ohrenheilkunde, III. 3. March, 1869 ; III. 4, April, 1869. 

2 Archives of Ophthalmology and Otology, II. 2, p. 37. 



250 DIAGNOSIS AND TREATMENT OF 

the orifice ; and in this decomposing fluid the eggs find a soil suitable for 
their development into living larvae. 

In certain cases the proliferative process in the tympanic mucous mem- 
brane takes place in an ear which still possesses an almost entire membrana 
tympani. These cases are comparatively rare, and they are usually very 
difficult to manage. I should like very much to discuss here in detail this 
rare but very attractive combination of lesions, but I can only give the his- 
tory of a single case, as the scope of the present treatise will not admit of 
the detailed discussion of a topic of such narrow limits. 

The patient, a girl six years of age, was brought to me by her mother 
on the 17th of July, 1879. About five months previously, as I was told, 
she had passed through quite a severe attack of scarlet fever, which left her 
with a double otorrhcea. On examination I found the left drum-membrane 
destroyed, and the mucous membrane of the middle ear in a granulating 
condition. The hearing-power of this ear was still quite good. On the 
right side I found the inner end of the meatus filled with a soft polypoid 
growth, which concealed the deeper parts of the ear. By aid of the snare 
I removed the greater part of this polypus. I found that it sprang from 
some portion of the mucous membrane of the middle ear, and that its pe- 
duncle emerged through a circular perforation (about two millimetres in 
diameter) in the membrana tympani, just below the tip of the handle of the 
hammer, and then branched out into two distinct lobes, which together 
formed a mass about as large as a large pea. Assuming that the growth 
sprang from the upper portion of the tympanic cavity posteriorly, I gave 
the wire loop such an inclination to the silver canula that I was able to re- 
move all visible portions of the polypoid growth. In other words, so far 
as I could see through the perforation into the cavity of the tympanum, 
every trace of the polypoid growth had been excised. 

On the 4th of August, the patient having returned from the country, I 
examined the ear again, and found that a dry, cicatricial membrane had 
grown over the former opening in the drum-membrane. On touching tins 
cicatricial portion, however, with the probe, I was surprised to find that it 
offered the same degree of resistance that one would expect to find in a 
moderately tough polypoid growth. No appreciable improvement had 
taken place in the hearing. 

On the 6th of August, that is, about forty-eight hours later, I was as- 
tonished to find in the place of the cicatricial membrane a moist, succulent, 
but not granulating surface. My interpretation of this apparently sudden 
•change was this : the slow growth of the intratympanic polypoid mass, and 
the unusually slight quantity of pus formed during the growing process, 
had allowed the perforation an opportunity to heal by the formation of a 
cicatricial membrane. Then the increasing pressure from within, exerted 
by the growing tumor upon the thin cicatricial membrane, had caused the 
two to unite into one continuous mass of tissue, and as a result of this 



DISEASES OF THE EAE. 251 

union the outer cicatricial portion had assumed some of the characteristics 
of granulation-tissue. Already on the 4th, when I examined the ear, the 
polypoid growth had reached the plane of the cicatricial membrane, and 
communicated to it that semi-solid condition which puzzled me not a little 
at the time ; but it was not until the 6th that the union had become suffi- 
ciently intimate for the latter membrane to assume some of the character- 
istics of the deeper growth. 

The child returned with her parents on the 6th to their home in Ne- 
braska, and I did not see her again until the 5th of December, 1879. The 
discharge had reappeared in the right ear during this interval, . and had 
become quite abundant. On examination I found that the appearances 
presented by the right membrana tympani had changed very materially. 
In the first place, the membrane as a whole had been drawn inward beyond 
the position which it had previously occupied. Quite low down anteriorly 
there was a very small perforation. Touching different parts of the mem- 
brane gently with the probe, I found that it offered solid resistance through- 
out the central portion ; in other words, it had become amalgamated with 
the mucous membrane of the inner wall of the cavity. While at all other 
points the drum-membrane presented a pale and tough appearance, that 
portion which corresponded to the former cicatrix was of a pale purplish 
hue, and perhaps a trifle more concave than the surrounding portions. So 
far as I could ascertain, the Eustachian tube was impervious to air. For 
the purpose of arresting the discharge, I injected into the middle ear 
daily, for four or five days, a five-grain solution of nitrate of silver, by 
means of the middle-ear pipette. Under this plan of treatment the dis- 
charge ceased on the fourth or fifth day. 

On the 15th of January, 1880, I found the right drum-inenibrane per- 
fectly dry and free from any evidence of active irritation. A very minute 
perforation still remained in the anterior inferior quadrant. In front of 
the perforation, and also posteriorly near the periphery, the membrane 
seemed, when I pressed upon it with the end of the probe, to be free. All 
the intervening central portion, however, appeared to be solidly amalgama- 
ted with the mucous membrane of the opposite wall. As no discharge 
had made its appearance for several weeks, I allowed the patient to return 
home. 

Sometimes the proliferative tendency restricts itself to the membrana 
tympani. In one case, for example, I made the diagnosis of a simple un- 
complicated otitis media purulenta chronica, and treated the patient for 
weeks without success. Finally, I one clay noticed something of a pinkish 
hue just beyond (i.e., on the inner side of) the edge of the small perforation, 
and, on closer investigation, found it to be a small polypoid growth which 
sprang from the inner aspect of the edge of the perforation. With some 
trouble I managed to get a fine wire loop around the growth and succeeded 



252 DIAGNOSIS AND TREATMENT OF 

in cutting it off close to the drum-membrane. The discharge, which had 
previously resisted every effort to arrest it, then stopped as if by magic. 
In this particular case I did — in a moment of desperation — what I would 
not advise others to do : I instilled a very strong solution of nitrate of silver 
(120 grains to the ounce) into the external auditory canal, and then forced 
it through the perforation and through the Eustachian tube. The opera- 
tion was followed by severe pain in the ear and by nose-bleed. Both symp- 
toms, however, lasted but a short time, and the discharge was reduced to a 
minimum for several days. 

In a second case, in which the discharge was very slight, I found a 
sharply defined, pedunculate polypus growing from the edge of the rather 
small perforation and resting against the outer surface of the membrana 
tympani. The removal of the growth with the snare, which was of course 
effected very easily, caused the discharge to cease and a scab to form over 
the perforation. Fifteen days later I had an opportunity of examining the 
ear again, and found the scab still occupying the same position. 

I might mention briefly in this connection certain peculiar lesions which 
I have encountered thus far only twice. I refer to the development of a 
granulating condition in an old cicatrix of the drum-membrane, without 
the re-establishment of a perforation. In the first case the patient, a laborer, 
twenty-six years of age, had been subject for a short time, about a year 
previously, to a discharge from the right ear. The discharge gradually 
diminished and finally ceased ; but at the time when I saw him (November 
22, 1873) it had reappeared. On examination I found the right membrana 
tympani red, swollen, and smooth everywhere except over the greater por- 
tion of the posterior superior quadrant. Here the membrane presented a 
bright red and granulating surface, which bled upon the slightest touch. 
To this region I applied a forty-five-grain solution of nitrate of silver, by 
means of a cotton mop. 

On the 29th of November I found that the granulating portion of the 
membrane had apparently become scabbed over. When I inflated the 
middle ear, the posterior superior quadrant of the membrane remained for 
a few moments in a markedly bulging condition, showing almost conclu- 
sively that no perforation existed at this point, and also that the membrane 
in this region had lost its substantia propria. 

In the second case the ulcerated or granulating spot was circular in 
shape and occupied the central portion of the lower half of the membrane. 
In this case I resorted to inflation before the part had become scabbed over. 
The result was that the ulcerated portion alone responded visibly to the 
increased aerial pressure within the tympanum. It would seem, therefore, 
as if cicatrices of the drum-membrane were in a measure predisposed to 
ulcerative action. 

We come now, finally, to the consideration of the measures that may be 
employed to advantage in removing polypi or masses of granulation-tissue 



DISEASES OF THE EAE. 253 

from the middle ear. Very few surgeons at tiie present day advocate the 
removal of aural polypi (i.e., growths of an appreciable size) by any other 
than mechanical means. The slow, unsatisfactory, and sometimes painful 
plan of destroying them by caustics or astringents has been very generally 
abandoned. If a large polypus fills the external auditory canal and pre- 
sents itself within easy reach at the outer orifice, an ordinary dressing-for- 
ceps, or better yet, Hinton's polypus-forceps, will serve the desired pur- 
pose as well as any other instrument with which I am acquainted. The 
mass is firmly grasped between the blades of the forceps, and is then 
separated front its deeper attachments by a combined rotary and pulling 
motion, or simply by direct traction. Farther on I will state under what 
circumstances traction is not to be employed. If the polypus, however, is 
situated more deeply in the canal, and reflected light is required to render 
the mass visible, such an instrument as Hinton's forceps — unless the canal 
happens to be unusually large — will be found awkward to manage and 
productive of pain to the patient. Blake's snare 1 is the proper instrument 
to use under these circumstances. By aid of the slender silver probe the 



1 This instrument, which was introduced by Dr. Clarence Blake, of Boston, in 1SG9 
or 1870, is sometimes spoken of as "Blake's modification of Wilde's snare." Those, 
however, who have compared the two instruments, and know from practical experience 
how different they are from each other, will agree with me that the more recent instru- 
ment is justly entitled to the name of "Blake's snare." In 1872 or 1873 the instrument 
was still further improved by the substitution of a simple canula of soft (pure) silver 
for the double-mouthed steel or G-erman-silver tube usually sold with the instrument. 
The pure silver canula measures three inches (8 ctm.) in length and but one millimetre 
in diameter (externally) throughout its entire length (except where it fits into the han- 
dle), while the steel or German-silver one measures two millimetres in diameter, and 
at the flaring end over two and a half millimetres. In cases where the external auditory 
canal is narrow, or where it is found necessary to remove a polypus which is situated 
within the tympanic cavity and which can only be reached through a comparatively 
small perforation in the membrana tympani, the great advantage of the slender silver 
canula is very apparent. But this is not the only advantage. In the double- mouthed 
canula the wire does not cut entirely through the polypus ; a slender connecting cord 
of tissue always remains uncut between the wire and the septum which separates the 
two mouths of the canula. With this canula, therefore, the last step of the operation 
always consists in the tearing asunder of this connecting bridge of tissue, — a pro- 
cedure necessarily more or less painful to the patient. In the simple silver canula 
the wire, on being withdrawn into the tube, cuts the polypus off entirely at the point 
of seizure, all necessity for traction being thus done away with. As a result of this, 
the operation of removing a polypus from the ear is in very many cases an almost pain- 
less procedure. Finally, the employment of very fine malleable steel wire (size=No. 
37), may be designated as the latest improvement which has been introduced in connec- 
tion with Blake's snare. Wire of this size possesses all the strength required for the 
removal of the great majority of polypi, and at the same time causes far less pain to 
the patient, whenever it comes in contact with the healthy and very sensitive walls of 
the auditory canal or of the middle ear, than does the heavier wire hitherto commonly 
employed. 



254 DIAGNOSIS AND TKEATMENT OF 

physician can ascertain whether the mass grows from the cutaneous walls 
of the canal or from the middle ear or mastoid cells. Where the growth is 
of such size as to fill the canal, it is not necessary that he should satisfy 
himself of the exact situation of the base of the polypus before applying 
the loop of wire. It is sufficient for him to ascertain by actual probing 
that he can pass his snare over the mass to a given depth (distance from 
the orifice of the meatus) without encountering any obstacle. The loop is 
then pushed in over the mass to this depth and tightened sufficiently to 
hold the polypus firmly in its grasp. If the growth is succulent and not 
very firm, and especially if it can easily be rotated about its long axis, 
steady traction should be made, in the hope of pulling out the polypus, 
peduncle and all. In not a few cases this object will be attained ; but even 
if the effort fail to remove the entire growth, at least as much of the mass 
will be torn off as would have been if the wire had been made to cut through 
the polypus instead of simply grasping it firmly. If the growth is firm in 
texture and not easily rotated, it is better to use the loop simply as a means 



o 



F.e otto St sons. 




Fig. 19.— Blake's Polypus Snare. (About half the natural size.) 

of cutting off portions of the growth. The same remark applies to the use 
of Hinton's polypus-forceps. Where the growth is firm in texture and firm 
in its deeper attachments, traction must not be employed. As soon as the 
bleeding has ceased, and the portion cut off by the wire loop has been re- 
moved with the bent forceps, the remainder of the growth is to be treated 
in precisely the same way as the first portion. The wire loop is to be ap- 
plied again and again until the base of the growth has been cut away to 
the level of the surrounding mucous membrane or skin. If the polypoid 
mass springs from some portion of the external auditory canal, it will be 
found as a rule decidedly firmer in texture and more sensitive than one of 
middle-ear origin. It will also not possess the same degree of mobility as 
the latter. In polypi of middle-ear origin we shall find that they spring- 
more frequently from the upper and posterior portion of the tympanum 
(entrance to the antrum) than from any other locality. 

It is a good rule in practice not to resort to the use of caustics until the base 
or peduncle of the polypus has been cut away with the snare to the level of the 
surrounding parts (skin or mucous membrane). Furthermore, in deciding 
whether the peduncle has been cut away to the proper level, we are not to 
trust to the sense of sight alone ; the behavior of the peduncle, when circum- 
scribed by the end of the probe, furnishes the only trustworthy guide to a knowl- 



DISEASES OF THE EAR. 255 

edge of the exact relations ichich this peduncle bears to the surrounding parts. 
When the mass has been so far extirpated that we cannot encircle it with a 
wire, we may, with benefit to the patient, resort to the use of caustics and 
astringents. 

Before speaking, however, of the after-treatment, it would perhaps be 
well to consider for a moment the dangers, real or apparent, which sur- 
round the operative procedure just described. 

As regards hemorrhage from the torn or cut surface of the mass, we need 
entertain very little anxiety. In malignant growths alone have I ever seen 
or heard of any loss of blood that could fairly be termed serious ; and only 
once have I encountered anything like an arterial hemorrhage, requiring 
the use of a tampon or plug. 

As regards the question of inflicting damage upon the apparatus of 
hearing in the middle ear, I have no doubt that clumsy and unskilful oper- 
ative interference may result in serious impairment of the hearing. The 
hammer, however, and the firm ridge in front of and behind Shrapnell's 
membrane, afford an excellent protection to the more deeply situated stir- 
rup, which is by far the most important piece in the mechanism of the 
middle ear. Polypi are occasionally encountered whose peduncles include 
in their substance the handle of the hammer (the rest of the membrana 
tympani being destroyed). In such cases the wire should be applied with 
caution, and no traction whatever should be employed. The few polypi of 
this kind which have come under my observation were quite small, and 
were attached to the ossicle by rather slender peduncles. In one of them, 
however, I made the very mistake which I am now cautioning against (i.e., 
I applied the wire to that portion of the peduncle which included the han- 
dle of the hammer), and only discovered my error by finding that the wire 
loop could not be drawn back into the canula. By cutting the wire loose 
from the instrument and pulling upon one end of it, no difficulty was 
experienced in disengaging it from the ossicle. 

Besides hemorrhage from divided vessels and injuries to the ossicles, I 
know of no other danger which may arise in the course of the operation for 
removing an aural polypus. 

As regards the after-treatment, this must be modified according to the 
location from which the growth springs. If the polypus grows from the 
cartilaginous portion of the outer canal (as a result, for instance, of an ab- 
scess in this locality), and is firm in consistency, the application of nitrate 
of silver in solid form to the base which remains after the removal of the 
fleshy mass, will act rather as a stimulant to further growth. Fuming 
nitric acid, applied cautiously but thoroughly to the base, is the only 
remedy upon which we can depend to arrest promptly a further reproduc- 
tion of the growth. As the fumes of the acid are apt to prevent the opera- 
tor from seeing clearly what he is doing, an instrument called a " porte- 
acid " has been devised, which enables the physician not only to apply the 



256 



DIAGNOSIS AND TREATMENT OF 



acid accurately to the desired spot, but also to confine its action in great 
measure to the region immediately cauterized. This instrument consists 
of a slender glass tube (about ten centimetres in length, not quite two 
millimetres broad, and somewhat flaring at both ends), through which a 
platinum wire of moderately small size passes. One end of the 
wire is bent upon itself, so as to prevent the mop of cotton-wool, 
which is wound round it, from falling off. When the instrument 
is to be used, the wire should be first pushed into the tube far 
enough to carry the mop end of the wire well outside of the flaring 
end of the tube. The mop having been dipped into the acid, the 
other end of the wire is then to be pulled out far enough to draw 
the mop well back into the flaring mouth of the tube. The base 
of the growth having first been thoroughly dried, the flaring end 
of the tube should be placed firmly upon the raw surface, and, 
while it is in this position, the mop should be pushed down firmly 
for an instant against the part to be cauterized. The reaction which 
follows is very slight, and the pain is of but short duration. The 
best way to remove the mop from the platinum wire is to burn it 
off in the gas flame. 

In a few cases of middle-ear polypi, it will be found advan- 
tageous to apply nitric acid to the base of the growth in the man- 
ner just described. Where the base, for example, is unusually 
broad and firm in texture, nitrate of silver is apt to act rather as a 
stimulant to further growth, while nitric acid will much more surely 
repress the tendency to grow. In these cases, however, the acid 
should be applied with great caution. The firm pressure which it is 
perfectly proper to use in the case of growths in the 
external auditory canal, would here be likely to produce 
a very unpleasant reaction. As regards the employment 
of such reagents as chromic acid, acid nitrate of mercu- 
ry, acetic acid, sulphate of copper, etc., for the purpose 
of checking the growth of granulation-tissue or polypi, 
my own experience has led me to abandon them all. 
Acid nitrate of mercury is a very treacherous remedy ; 
it seems to penetrate to a much greater depth than ni- 
trate of silver, or even nitric acid, and is apt to be fol- 
lowed by considerable pain. Chromic acid, in my ex- 
perience, is also rather treacherous. As I have used it 
only in a crystalline state, however, it is not unlikely 
that my prejudice against this much-praised caustic is 
ill-founded. It should be used only in a fluid state. Absolute alcohol can- 
not be used properly unless it be made at the same time to bathe all the 
surrounding healthy tissues. Its effects seem to be superficial and evanes- 
cent. In the great majority of cases, pure nitrate of silver, fused upon the 




Fig. 20.— Glass "porte- 
acid" with platinum cot- 
ton-holder passing through 
its interior. (Natural size.) 



DISEASES OF THE EAE. 257 

end of a cotton-holder or probe in the form of a rounded bead, will be found 
the most convenient, most efficient, and least painful of all the caustics. 
Each application should be followed by the mopping process with the cot- 
ton-holder, in order that the caustic may not spread beyond the limits of 
the diseased locality. 

Oftentimes a single cauterization will suffice to complete the levelling 
process begun by the wire snare. In a few cases the snare will be found 
to have done its work so effectually that the intermediate stage of the treat- 
ment — that of cauterization — may be omitted altogether. It should be 
clearly kept in mind that the caustic is to be used for the express purpose 
of destroying the superficial portions of the stump of the growth, in order 
to bring it down to such a level that the surrounding healthy mucous mem- 
brane may grow out from all sides over the mass, and so furnish it with a 
natural covering of mucous membrane. 

That nitrate of silver also exerts a beneficial astringent action, — that it 
sometimes seems to restrain in a most remarkable manner the tendency to 
the production of lymphoid elements (pus- or tissue-forming cells), cannot 
be denied by any one who is in the habit of using it much. In a large 
number of cases, however, it produces the very opposite effects. Hence the 
desirability of resorting as soon as possible to the use of pure astringents. 

The third and last stage of the treatment consists in the application of 
astringents to the remaining stump of the growth. The parts are to be 
thoroughly dried with the mop of absorbent cotton, and then powdered 
burned alum or iodoform (or a mixture of the two) is to be laid upon the 
dried surface freely but not too thickly. By moistening the end of the 
slender silver probe and then dipping it into the powder, one can readily 
take up quite a large mass, which will cling to the end of the probe with 
sufficient tenacity to enable the physician to transfer it to the desired spot 
in the middle ear or outer canal. These pellets of powder are to be 
applied again and again, until the granulating surface is well coated with 
the remedy. In a few cases I have observed that iodoform (finely pow- 
dered) has been able to completely arrest all further growth and all 
secretion of pus, when the alum had failed to accomplish the desired 
result. In my hands the iron and tannin preparations have not proved 
so efficient as the two remedies just mentioned. 

If all these efforts fail to arrest the otorrhcea, we may safely draw the 
conclusion that a carious condition of some portion of the temporal bone 
(the posterior end of the tympanic cavity, in the majority of the cases), or 
an undiscovered granulation-growth is the source of the continued dis- 
charge. In regard to hidden growths, our best course is to abandon all 
active treatment and to siniply examine the ear at longer intervals (say once 
in three or four months). After a varying length of time the growth may 
attain such a size as to encroach upon some visible part of the ear, when it 
will readily be discovered if the physician examines carefully. 
17 



258 DIAGNOSIS AND TKEATMENT OF 

Finally, in a limited number of cases, the external auditory canal is so 
narrow, or the anterior or lower wall so prominent, that we cannot obtain 
a view of the spot from which the polypus springs, although the greater 
part of the growth can readily be distinguished and easily removed. In 
these cases we are quite likely to experience defeat, so far as the attainment 
of a perfect cure is concerned ; but the removal of the greater part of the 
mass will, as a rule, greatly diminish the otorrhcea, and oftentimes also im- 
prove the hearing, for a period of several weeks or even months. 

If I have said nothing about the removal of polypoid growths by means 
of the galvano-cautery wire, it is simply because I cannot see what advan- 
tage is to be gained by the use of this instrument. Blake's snare fully 
meets all the requirements of the case, and in the matter of simplicity and 
cheapness it is far superior to the complicated galvano-cautery. 

Foreign bodies in the middle ear. — As my only experience with this rare 
condition relates to a case of chronic purulent inflammation of the middle 
ear, of the proliferative variety, I may with propriety give a detailed ac- 
count of it in this place. The patient, a lady about sixty years of age, con- 
sulted me on the 24th of March, 1879, for a painful affection of the right 
ear. According to her statement, she had had a slight discharge from the 
right ear all her life. About the first of March of that year she noticed that 
her hearing was more dull than usual, and, at the suggestion of a friend, 
she consulted a physician. He gave her very little encouragement, but 
said that she might experience some relief by wearing an artificial drum- 
membrane, and, with her permission, he introduced one into her ear. As 
this artificial membrane, however, did not improve her hearing, but, in- 
stead, caused her considerable discomfort, he undertook to remove it. 
Although he failed, as will be seen, to accomplish his object, he in a meas- 
ure satisfied the patient that the membrane had been removed. From that 
time forward the ear had grown more and more painful, and she had lat- 
terly experienced considerable pain throughout the entire right side of the 
head. At the time when I saw her she presented the appearance of a per- 
son who had passed through a prolonged period of suffering. On examina- 
tion I found the inner half of the canal filled with a soft polypoid mass, 
bathed with moderately thick pus. I removed the growth with the snare 
and found that it sprang from the edge of a moderately large perforation in 
the drum-membrane. In the centre of the opening I noticed something 
of a peculiar grayish white color, and on touching it with the probe I discov- 
ered that it consisted of some hard material which was firmly lodged in the 
cavity of the tympanum. By aid of the slender angular forceps I succeeded 
in extracting this foreign body, which proved to be a rather thick disk of 
whitish rubber, in the central portion of which was a small hole for the 
reception of a thread. This circular piece of rubber was of almost precisely 
the same size and shape as the normal drum-membrane. 



DISEASES OF THE EAR. 259 

After this foreign body had been removed from the middle ear the pain 
soon disappeared entirely, the discharge became again insignificant, and 
when I examined the ear, after the lapse of about ten days, I found a per- 
fectly smooth and unirritated drum-membrane, in the centre of which was 
a circular perforation not more than three millimetres in diameter. No 
further treatment was advised. 

It is difficult to understand how any physician, possessed of his senses, 
could have deliberately done such a foolish thing as to force a compara- 
tively large disk of rather stiff rubber through an opening in the drum- 
membrane scarcely three millimetres in diameter. And yet the condition 
in which I found the ear showed very clearly that the rubber disk had been 
placed deliberately in the situation where I found it. ' 

III. Cases in which the Bone is Involved. 

The pathology of these cases is often difficult to determine. Imprison- 
ment of the pus during the original acute attack is probably, in very many 
cases, the cause of the carious process in the bone. The imprisoned pus 
subjects the mucous membrane of the middle ear to great and prolonged 
pressure, and, as a consequence of the resulting interruption in the circula- 
tion, death may take place at one or more points in the membrane. As the 
mucous membrane, however, is also at the same time a periosteum or nour- 
ishing membrane of the bone, the superficial portions of the latter at the 
points mentioned are also apt to die. This explanation will perhaps often 
suffice for those limited spots of caries which are so frequently found in the 
middle ear, but it will scarcely account for the extensive areas of necrosis 
which are sometimes encountered. In such cases we must assume that 
other processes, perhaps embolic in their nature, 2 have contributed chiefly 
to the production of the result in question. Schwartze, in his " Treatise on 
the Pathological Anatomy of the Ear," mentions the extension of a simple 
ulcerative process from the mucous membrane to the subjacent bone as one 
of the common ways in which caries of the middle ear is produced. In the 
more serious cases, however, of caries or necrosis of some portion of the 
temporal bone, it will almost invariably be found that retention of pus, and 
especially of cheesy and decomposing, pus, in the tympanum proper or in 
the mastoid antrum, is in some way connected with the disease of the bone. 
This clanger lurks in every case of chronic purulent inflammation of the 



1 For other instances of the presence of a foreign body in the middle ear see : 
Noyes, Transactions of the Amer. Otol. Society, 1870 ; Israel, Berlin, klin. Wochen- 
echrift, 1876, No. 15 ; Voltolini, Monatsschrift fur Ohrenheilkunde, May and June, 
1876; Schalle, Berlin, klin. Woch. No. 31, 1877; Voltolini, Monats. f. Ohrenh., 
Aug. 1878. 

2 See Trautmann : Archiv fur Ohrenheilkunde, XIV. p. 73. 



260 DIAGNOSIS AND TREATMENT OF 

middle ear, and is particularly to be dreaded in those cases that are charac- 
terized by a small perforation in the drum-membrane, or by one located in 
Shrapnell's membrane. 

The cases that belong in this third subdivision may readily be divided 
into several smaller groups, in accordance with the differences in the parts 
involved, in the symptoms manifested, in the issue of the disease, etc. 

1. Superficial caries, with unobstructed outlet for the discharge. — In cases 
of the proliferative variety it is a very common experience to find, in the 
immediate neighborhood of the mass of granulations, or at the base of the 
polypoid growth, a spot of exposed and roughened bone. The favorite sit- 
uations for such spots of bone-caries are the posterior wall of the tympa- 
num, just below the entrance to the antrum, the bony floor of the tympa- 
num, near the posterior end of the cavity, and the ridge of bone separating 
the middle ear from the external auditory canal. In two cases I found the 
mucous membrane of the promontory very much thickened (the drum-mem- 
brane had been totally destroyed), and on manipulating it with the probe 
I discovered that, below, it was not continuous with the mucous membrane 
covering the floor of the tympanum, but ended in a thickened and rounded 
edge, which could be lifted up like a hanging curtain. The end of the 
probe, passed beneath the edge of this fleshy curtain, encountered quite an 
extensive surface of denuded but smooth bone. 

In cases that belong to the present group I am not in the habit of modi- 
fying my mode of treatment materially. The plan suggested by some au- 
thorities, of subjecting the bone at these spots to a thorough scraping with 
some sharp instrument, does not commend itself at present to my judg- 
ment. The principle is undoubtedly sound, but the application of it to a 
carious spot of unknown depth and extent does not appear to me to be safe- 
ly practicable. The removal of the granulation-tissue or polypus, as the 
case may be, the careful daily cleansing of the ear with lukewarm water 
(with or without the addition of boracic acid), and the judicious application of 
caustics or astringents to the proliferating mucous membrane, will be found 
to produce fairly satisfactory results. So long as the outlet is sufficiently free 
—as it is in cases where the perforation in the drum-membrane is large, or 
where the membrane is entirely destroyed — this group may be considered 
as identical, in all essential particulars, with that of the proliferative cases. 

2. Caries with more or less obstructed outlet for the discharge. — Cases be- 
longing to this group are not very numerous, but they furnish a large pro- 
portion of the deaths from ear disease. In the present section, however, I 
propose to consider only the more favorable cases belonging to the group. 
It is in these alone that we can study quietly the ordinary course of this se- 
rious form of disease of the ear. The early stages of the malady can only 
be inferred from the lesions observed at some latter stage of its course. 
The whole picture, however, points clearly to the lack of proper treatment 



DISEASES OF THE EAR. 261 

during the early stages of the acute attack. I will give the details of one 
or two well-marked cases : 

Case I. — The patient, a strongly built man, thirty-eight years of age, con- 
sulted me on the 15th of May, 1874, on account of a very offensive odor 
which came from his left ear. He stated that he had had scarlet fever dur- 
ing childhood, and that from that time forward, with occasional short inter- 
missions, he had been troubled with a scanty but offensive discharge from 
the left ear. Inspection revealed the existence of two perforations : one 
situated in the posterior fold, involving a little of the drum- membrane 
proper ; the other involving only the anterior fold and part of the bony 
ridge above it. Both perforations partook rather of the nature of fistulous 
tracks communicating with some more deeply situated centre of disease, 
than of that of simple perforations. In other respects the membrana tym- 
pani was a fairly healthy, though much thickened membrane. A little 
dark-colored and very offensive secretion was found in the neighborhood of 
the fistulous openings, but elsewhere the parts were quite clean and dry. 
The edges of the posterior opening were in a slightly granulating state. 
As there was no evidence of active local irritation, I advised the patient to 
douche the affected ear very gently about three times a week, simply for 
the purpose of removing the foul discharge from the meatus. 

On the 30th of March, 1875, the patient came to see me again. He had ex- 
perienced considerable pain in the left ear during the previous three days. 
I examined the ear and found the soft parts surrounding the anterior open- 
ing red and swollen, and the orifice of the sinus obliterated. Treatment : 
two leeches to be applied to the tragus, and the ear to be frequently douched 
with warm water. 

These measures relieved the pain, and the patient was then not seen 
again until September 9, 1876. He had for a short time previously suffered 
considerably from dizziness, and the discharge from the ear had increased 
in quantity. On examination I found the inner end of the meatus occu- 
pied by quite a large, two-lobed polypoid growth. I removed it with the 
■wire loop, and found that its peduncle occupied the posterior fistulous 
opening. 

On the 13th I removed a portion of the peduncle with the snare, carry- 
ing my wire loop a short distance into the fistulous opening. 

On the 16th I succeeded in passing the wire-loop deep down into the 
fistula, and in cutting off the peduncle at a point probably very close to its 
actual base. "With the porte-acid I then made an instantaneous application 
of nitric acid to the remaining stump at the bottom of the fistula. 

On the 18th I noticed for the first time that a small knob of granulation- 
tissue, about the size of a No. 3 shot, protruded from the orifice of the an- 
terior opening. By passing the wire loop over the mass and as far into the 
sinus as possible, I succeeded in removing probably the greater part of the 



262 DIAGNOSIS AND TKEATMENT OF 

growth. I also applied nitric acid to the base of this second growth. The 
pain following these applications of undiluted nitric acid was insignificant 
and of only short duration. 

On the 20th, and again on the 22d, I succeeded, with Blake's snare, in 
removing masses of granulation-tissue from the bottom of the posterior 
sinus. I also discovered that exposed and roughened bone could be reached 
with the probe in the vicinity of the entrance to the antrum. 

On the 25th the patient reported that the discharge from the ear had 
nearly ceased, and that he was completely relieved of his distressing dizzi- 
ness. 

On the 2d of October I was again obliged to employ the snare in both 
openings. On the 4th I could discover no trace of granulation-tissue in 
either fistula. I therefore introduced into them pellets of powdered burned 
alum. On the 7th and 10th I repeated the applications of burned alum, 
and then dismissed the patient, as the discharge had practically ceased. I 
advised him, however, to use the douche faithfully at least three times a 
week. 

On the 4th of January, 1877, he reported that a very slight discharge 
had persisted since his last visit. On examination I found a small mass of 
granulation-tissue at each of the two orifices. I used the snare in the same 
manner as on previous occasions, and then introduced powdered iodoform 
into the openings. 

From this time forward, patient remained almost free from discharge 
until shortly before the 14th of July, 1879, when I was obliged again to use 
the wire snare. (From that time to the present [September, 1880] I have 
not seen the patient.) 

Case II. — The patient, a merchant, thirty years of age and in good gen- 
eral health, consulted me on the 21st of October, 1878, for an offensive dis- 
charge from the left ear. He stated that about four months previously he 
had experienced severe pain in that ear, and that after the lapse of a few 
days a discharge had made its appearance and had continued steadily since. 
At times the discharge had been tinged with blood. On examination I 
found the left auditory canal noticeably smaller than the right. It con- 
tained a moderate amount of brownish, offensive secretion. The membrana 
tympani was very opaque, but smooth, uninflamed, and possessing, appar- 
ently, the normal degree of curvature. Just above and in front of the short 
process of the hammer there was a small excavation, filled with a dark-col- 
ored cheesy material. The tissues immediately surrounding it were red 
and somewhat swollen. By means of a curved probe I ascertained that this 
excavation was in reality the outer orifice of a sinus which led inward and 
a little upward, probably to the upper part of the tympanic cavity. From the 
appearance of the membrana tympani at that time, and from the subsequent 
course of the disease, I suspect that the cavity which supplied the pus was 



DISEASES OF THE EAR. 263 

shut off from the general cavity of the middle ear by a partition of adventi- 
tious tissue or by the prolapsed and thickened mucous membrane belong- 
ing to the upper wall of the tympanum. For a short time I made the at- 
tempt (by thoroughly cleansing the sinus and by the application of caustics 
and astringents) to diminish the quantity and the offensiveness of the dis- 
charge, but I failed to accomplish this object. 

On the 27th of October, 1879, I was sent for by the patient, as he was 
too ill to leave his bed. He was in considerable suffering, and stated that 
the pain in the left ear had developed three days previously, and had stead- 
ily increased in severity up to that time. Leeches had been applied by his 
regular medical attendant, but they had afforded only temporary relief. I 
examined the ear and found that a red, conical swelling occupied the situa- 
tion of the former excavation, and that from a small opening in the apex of 
this swelling pus was escaping. Believing that the patient's suffering was 
largely due to the inadequateness of the outlet for the pus, I made a free in- 
cision through, the centre of the conical swelling. 

I was not sent for again until the 5th of November. The patient then 
stated that the operation had relieved the severe pain, and had rendered the 
discharge quite active, but that every day, and especially toward night, he 
had experienced a dull pain throughout the entire left side of the head. He 
had also been very much annoyed by dizziness. On examination I found 
the inner end of the meatus filled with a large, succulent polypoid mass. I 
removed it with the snare, and found that it grew from the region of the 
former excavation. I also found, on probing the sinus, that it contained a 
small fragment of exfoliated bone. On withdrawing the probe I brought 
to the orifice of the sinus some white cheesy material. 

The removal of the polypoid growth afforded considerable relief for a 
short time, but on the 29th of November he came to see me again, as the 
pain was steadily increasing. To my surprise, I found the external audi- 
tory canal almost filled with a polypoid growth. I removed it thoroughly 
with the snare. 

On the 20th of December I found the condition of the ear materially 
changed. The polypoid growth had not reappeared, but equivalent changes 
had taken place in the cavity of the tympanum. The drum-membrane ap- 
peared to have become amalgamated with an intratympanic growth, which 
had already attained such dimensions that the visible background, at the 
bottom of the meatus, appeared like a solid, rounded mass of flesh. There 
was nothing in the appearance of the mass to remind one that its outer por- 
tion, at least, consisted of the membrana tympani. At one spot, near the 
floor of the canal, this otherwise tough-looking mass appeared to be granu- 
lating, and on pressing my probe against the spot it passed readily inward 
to a distance of about one -third of an inch. The dizziness and pain still 
persisted, and the patient was unable to attend to business. 

On the 10th of January, 1880, I removed with the snare a rather large 



264 DIAGNOSIS AND TREATMENT OF 

polypoid mass winch sprang by a slender peduncle from the lower part of 
the drum-membrane. Since the 20th of December a very noticeable change 
had taken place in the condition of these deeper parts. The membrana 
tympani still occupied an unnatural position, but it was evident that the 
intratympanic growth had diminished very decidedly in size, as the mem- 
brane then protruded only to a moderate degree. 

On the 10th of February the patient reported that he was almost en- 
tirely free from dizziness and pain in the head, and that the discharge had 
greatly diminished in quantity. On examination, I found everything re- 
stored to the state in which I had found the ear in October, 1878. The 
drum-membrane was entire and occupied a very nearly natural position ; 
no granulating surface was anywhere to be seen ; in a word, the only dif- 
ference that I could discover was a slight enlargement of the orifice of the 
sinus — and of this, even, I could not be positively certain. 

The preceding cases suggest two points with regard to which I should 
perhaps say a word or two. In the first place, in both of these cases 
marked dizziness was a prominent symptom, and in both it seemed to de- 
pend upon increased intratympanic pressure. In these cases, therefore, of 
caries with obstructed outlet for the pus, we should make use of this symp- 
tom as a measure of the degree of obstruction that exists, and as an indi- 
cation that we should interfere for the purpose of re-establishing a free 
outlet. In the second place, the obstacles that stand in the way of a suc- 
cessful treatment of this pathological condition are very great. As a rule, 
we are obliged to rest satisfied with only partial success. 1 

3. Extensive caries or necrosis of the temporal bone. — The few cases of 
this nature that I have seen, came under my observation for the first time 
only after the damage had been done. I am therefore unable to throw any 
light upon their pathology, but can simply record the nature and extent of 
the damage found at the time of my examination. Thus, for example, in 
the case of a boy, seventeen years of age, I found all that part of the squam- 
ous portion of the temporal bone, which separates the upper part of the 
tympanic cavity from the external auditory canal, destroyed. The anterior 
and posterior folds were still intact, and so was the drum-membrane proper. 
The head of the hammer, however, with the exception of only its extreme 
upper portion, stood out prominently in the centre of the irregularly shaped 
excavation. In a second case the anterior and posterior folds formed the 
dividing ridge between two cuts de sacs, —the upper one being formed by a 
carious excavation in the bone situated in front of the head and neck of 



1 For further information with regard to these perforations in the region of Shrap- 
nell's membrane, consult the articles by Blake and Burnett, in the Transactions of the 
American Otological Society for 1874 ; and one by Miller, in the volume for 1878. 



DISEASES OF THE EAK. 265 

tlie hammer, the lower one consisting of the exposed cavity of the tym- 
panum. In a third case the membrana tympani, the hammer and anvil, 
the anterior and posterior folds, and a large part of the bone situated above 
the drum-membrane, had all been destroyed. The appearance presented 
to the eye of the observer was as if the external meatus terminated in quite 
a cavern. Notwithstanding this extensive destruction of the parts, the 
hearing-power of that ear remained fairly good. In a fourth case I ex- 
tracted quite a large mass of bone from the external auditory canal, and, 
on examining it, I found it to consist of the larger part of the cell-structure 
of the mastoid process. I have never seen a case of necrosis and casting- 
off of the labyrinthine portions of the petrous bone, but many such have 
been reported. 1 There is even a case on record 2 where almost the entire 
temporal bone was cast off, as the result of necrosis. 

4. Desquamative processes. — Under ordinary circumstances the inflamed 
mucous membrane of the middle ear casts off pus, muco-pus, or a simple 
serous fluid. Under certain conditions, however, it casts off, in addition 
to these elements, layer upon layer of flattened or pavement epithelium. 
These layers, as a rule, are not floated out of the ear with the fluid portions 
of the products of inflammation, but show a disposition to adhere to each 
other and to the subjacent living tissues, thus forming laminated masses 
of epithelium which sometimes attain very large proportions. The laws 
governing the development of this desquamative process are not known. It 
is very commonly found associated with carious processes in the tympanum, 
mastoid antrum, or mastoid cells, but it is not always clear whether the 
irritating effects of the caries have called forth the desquamative process, 
or whether the pressure of the constantly growing mass of cast-off epithe- 
lium has produced the caries. In exceptional cases we may encounter such 
laminated masses of epithelium in a middle ear which presents no evidence 
of being the seat of a carious process. Thus, for example, in February, 
1878, I was consulted by a gentleman, who stated that since boyhood he 
had been affected with occasional, but very slight discharge from both ears. 
On examination I found in the left ear a fistulous opening in the anterior 
fold, and a small perforation in the posterior inferior quadrant. In the 
right ear I found a little watery secretion in the meatus, and an opaque and 
tough-looking membrana tympani, which at first sight appeared to be en- 
tire. On more careful inspection, however, I discovered a linear, slit- 
shaped perforation, perhaps two millimetres in length, running parallel 

1 For instance, by Toynbee, by Schwartze (A. f . 0. IX. , p. 238), by Dennert (op. 
cit., X., p. 231 and XIII., p. 19), by Lucse (ibidem, p. 236), by Agnew (American Med. 
Times, Vol. VI., No 16), by Pomeroy (Transactions of the American Otological Society, 
1872), and by Spencer (Transactions Missouri Medical Association, 1875). 

2 Dr. J. Gottstein : Archiv fur Ohrenheilkunde, XVI. Bd., Erstes and Zweites 
Heft. 



266 DIAGNOSIS AND TREATMENT OF 

with and close to the posterior periphery of the membrane. "When the 
patient performed Valsalva's experiment, the entire drum-membrane 
yielded to the pressure from within, just as an unbroken membrane would. 
From this behavior of the membrane I inferred that either a mass of mucus 
or a polypoid growth, acting like a valve, prevented the air from escaping 
through the perforation. I accordingly enlarged the opening in the mem- 
brana tympani by making two incisions, one at each end of the perforation 
and at right angles to it. By these incisions I converted one lip of the 
opening into a rectangular flap, and so secured a broad outlet. Inflation 
by Politzer's method was then resorted to, and as a result a whitish mass, 
three-eighths of an inch long, two-eighths of an inch broad, and about one 
millimetre in thickness, was driven out into the external auditory canal. 
Under the microscope small fragments of this mass were found to consist 
solely of flattened epithelium (non-nucleated). The removal of this large 
mass from the cavity of the tympanum gave the patient marked relief from 
an annoying sense of fulness in the ear, and also materially improved his 
hearing, but did not arrest the discharge. The patient remained under ob- 
servation for about four days, and was then obliged to return to his home 
in Ohio. 

It is a more common experience to find the laminated mass of epithe- 
lium filling the cavity of the tympanum, or at least its upper portion, as in 
the following case : 

Case I.— The patient, a lady about thirty years of age, consulted me on 
the 23d of November, 1878, for a painful affection of the left ear. Accord* 
ing. to her story she had had a discharge from this ear since girlhood, 
though not constantly. Eecently, however, the discharge had become 
quite active, and she had suffered from a steady, dull pain, which seemed 
to be most acute in the neighborhood of the mastoid process. Her head 
had also felt heavy and full. After removing two polypoid growths, which 
obscured the view of the deeper parts, I discovered that quite a large mass 
of tough, laminated epithelium filled the entire cavity of the tympanum. 
By dissecting the edges carefully I was able to loosen it and remove it as a 
single tough, leathery mass. A considerable portion of the bony ridge 
situated just above the drum-membrane had been destroyed, and the larger 
part of the epithelial plug was located in the excavation which remained. 
The polypoid growths sprang from the outer margin of this same exca- 
vation. The relief which the removal of this tightly fitting mass afforded 
the patient was apparently very great. 

On the 27th of December, the patient returned to the city and reported 
that she had carried out my instructions (simply to douche the ear daily 
with lukewarm water) faithfully, and that as a result the discharge had 
ceased entirely since the middle of the month. The pain and sense of dis- 
comfort in the head had also entirely disappeared. I examined the ear and 



DISEASES OF THE EAR. 267 

found the parts perfectly clean and pale, with no signs at any point of a 
tendency to develop granulation-tissue. 

The preceding case may be taken as a fair type of these not very rare 
cases. If one can judge correctly from the published reports of many of 
the best authorities, the mastoid antrum is the most frequent starting-point 
of such desquamative processes. 1 Marked variations from the type de- 
scribed above, however, are occasionally encountered. As an instance of 
such an exceptional course of the disease, I will narrate the following case : 

Case II. — The patient, a strong, healthy man, twenty-five years of age, 
had been subject to frequent earaches and to an occasional discharge from 
both ears since childhood. During the last three weeks of September, 
1875, he had experienced constant pain in the left ear. When I examined 
his ear on the 1st of October, 1875, I found the external auditory canal 
blocked with a red, fleshy mass, which sprang from the upper wall of 
the canal. The most prominent portion, which looked like ordinary granu- 
lation-tissue, was removed with the snare, and then it was ascertained that 
the fleshy mass which blocked the entrance of the external auditory canal 
was really the prolapsed upper cutaneous wall, in which an opening had 
established itself. A probe introduced into this opening could readily be 
passed in a distance of fully three-fifths of an inch, without encountering 
at any point denuded bone. Considerable cheesy and very foul pus was 
removed from the contracted meatus, but no view could be obtained of the 
deeper parts, owing to the fact that the prolapse of the upper cutaneous 
wall of the canal extended inward as far, apparently, as to the immediate 
vicinity of the membrana tympani. As this prolapsed portion could not 
be lifted back to its natural position, it was evident that some substance 
(cheesy pus, as I supposed) had accumulated between it and the bony wall. 
For its removal I adapted a slender nozzle (diam. 1-J- mm.) to an ordinary 
hard-rubber ear- syringe, interposing between it and the nozzle of the 
syringe a short bit of rubber tubing. This slender nozzle was introduced 
without any difficulty into the mouth of the sinus, and upon forcing in the 
warm water it was found that the greater part of it returned by the side of 
the nozzle, while the rest made its way through the sinus into the deeper 
parts of the ear, whence it escaped through the meatus proper. This pro- 
cedure caused the patient not a little pain, and consequently could be re- 
peated only a few times at a sitting. The first time (October 2d) almost 
nothing was brought away by the syringing, but on subsequent days the 

1 Consult Von Troeltsch (Arch. f. Ohr., IV., p. 105), Toynbee (Medico -chirurg. 
Trans., Vol. XLV.), Lucse (A. f. O., VII., p. 255), Duncanson (Edinb. Med. Jour., Nov., 
1877), Matthewson (Trans. Amer. Otol. Soc, 1878), Moos (Archives of Ophthal. and 
Otol., III., No. 2), and Kipp (Archives of Ophthal. and OtoL). 



268 DIAGNOSIS AND TKEATMENT OF 

stream of water regularly brought away fragments of epithelial laminae of 
the most perfect whiteness. The bent forceps was also frequently used in 
dislodging the larger masses, which were too large to pass through the 
orifice of the sinus except with the aid of some tractile force. On October 
10th (the syringe having been used daily in the meantime) the last frag- 
ment was dislodged. The total amount of epithelium removed was suffi- 
cient to fill a two-drachm bottle (no force being used to pack the substance 
into small compass). A microscopic examination revealed the presence of 
a few crystals of cholesterine in addition to the lamellae of large, polygonal, 
perfectly transparent, sharply outlined epithelial cells. From day to day, 
as the accumulation of epithelium became reduced in quantity, the calibre 
of the external auditory canal grew steadily larger, until, on the 11th of 
October, I was able to ascertain quite accurately by inspection the condi- 
tion of the middle ear and deeper portion of the meatus. There was at the 
same time a very perceptible improvement in the hearing. After the last 
mass of epithelium had been removed, the probe introduced into the sinus 
encountered roughened bone surface at the point where the posterior wall 
of the meatus becomes the outer surface of the mastoid process. Farther 
inward, however, the end of the probe passed over a series of small, smooth 
hummocks, which conveyed to my mind the impression of being the ex- 
posed septa of the mastoid cells (the solid bone composing the posterior 
and upper wall of the meatus having been destroyed by caries, — or possibly 
by pressure). At the farther end of the sinus, and encroaching slightly 
upon the posterior fold, w T as a second opening (in the cutaneous wall), 
which communicated with the inner end of the meatus, and was fringed 
like the outer one with granulation-tissue. Upon the removal of the granu- 
lations with the snare, the membrana tympani could be seen. It was still 
entire, but amalgamated at almost every point with the tissues of the inner 
wall of the tympanum. In the posterior upper portion, and in one or two 
places below, the membrane was still free. There was no swelling or ten- 
derness over the left mastoid process. 

As the patient died soon afterward (November 1st) at his home in 
Canada, from the results of long-standing disease in the right ear (an ac- 
count of which would here be out of place), I am unable to add further 
details regarding the complicated condition observed in the left ear. 

It is not easy to build up any theory that will satisfactorily explain all 
the aspects of this unusual case. Originally there was probably a severe 
inflammation of the middle ear, which, not finding a free escape for its pro- 
ducts through the membrana tympani, —that membrane probably being 
more resistant than usual, — extended to the antrum and adjacent cells. From 
this resulted in course of time a caries of that portion of the mastoid pro- 
cess which forms the posterior and upper wall of the external auditory canal. 
A fistulous opening then established itself in the cutaneous wall of the 
canal, and, as it was of small size and probably from time to time became 



DISEASES OF THE EAR. 269 

closed for a short time, the accumulating pus from the carious region must 
have dissected a way for itself in the direction of least resistance, that is, 
inward toward the posterior fold. At this point, too, the cutaneous wall 
is thinnest, and here it was that a second opening established itself. As 
the mastoid cells were found to be exposed over quite an extent, without 
at the same time being carious, a condition which I will not venture to ex- 
plain, it is fair to assume that the immense mass of epithelium found in 
this situation must have been cast off from the mucous membrane lining 
these cells, cheesy and foul pus haying originally supplied the necessary 
irritating stimulus. 

5. Extension of the ulcerative process to neighboring organs. — If we leave 
out of consideration for the present those cases in which the brain and its 
membranes and the lateral sinus are invaded by the disease, there still re- 
main those cases in which the chorda tympani neiwe, the facial nerve, and 
the carotid artery become affected. With the exception of a few cases of 
facial paralysis, the various conditions which I have just enumerated have 
never come under my immediate observation, and I am therefore unable to 
give any information based upon personal experience. Cases of fatal hem- 
orrhage from the carotid artery, dependent upon caries of the temporal 
bone, will be found in Marco's monograph on this subject. 1 The only in- 
stance that I can recall of an affection of the chorda tympani nerve, occur- 
ring in the course of a chronic purulent inflammation of the middle ear, is 
that reported by Xoyes. 2 

6. Cyst-like tumors of the drum-membrane. — I can find in my records but 
six cases of well-defined cysts of the membrana tympani. In four of them 
there had previously existed a purulent inflammation of the middle ear. In 
one of these four cases, which I reported in detail in 1872, 3 the cyst seemed 
to have formed between the layers of the drum-membrane. In the other 
three cases, however, the cyst-like tumor consisted of the posterior half of 
the drum-membrane, which, having lost its substantia propria through the 
prolonged pressure of the exudation in the tympanic cavity, had no longer 
been able to resist that pressure, and so gradually became converted into 
an elastic diverticulum. In acute cases I have frequently observed, during 
convalescence, a veiy marked pouting of the membrane in the immediate 
vicinity of the perforation ; and in one case, which is now under my care, 
I found on returning to the city, after an absence of a week, that the simple 
pouting of the membrane had developed into a well-defined, almost pedun- 



1 Marce \ De l'ulceration de la carotide interne dans la carle du roclier. 
1874. See also a case reported by Hermann (A. f . 0. , IT. , p. 294). 

2 Transactions of the American Otological Society, 1874. 

3 In the Medical Record of November or December of that vear. 



270 DIAGNOSIS AND TREATMENT OF 

culate cyst, fully three millimetres in diameter. A minute perforation still 
existed, but it was so inadequate, as an outlet for the purulent secretion, 
that the neighboring parts were kept in a constant state of tension. 

In the remaining two cases the cysts were of quite a different nature. 
One of them occupied the very centre of the drum- membrane and measured 
nearly three millimetres in diameter. It was also somewhat flattened, as if 
a portion of the fluid contents had been absorbed. The other cyst occu- 
pied the lower two-thirds of the posterior half of the membrane. It had 
evidently originated at the upper part of the membrane, and had, as it in- 
creased in size, dissected its way down to the lower part. Both of these 
cysts contained apparently pure serum, unmixed with blood. Both occu- 
pied spaces which they had made for themselves between the substantia 
propria and the outer dermoid layer. Both seemed to have originated in a 
subacute congestion of the middle ear, which had run its course, however, 
without causing any appreciable exudation in the tympanic cavity. After 
the contents had been evacuated, both cysts soon disappeared completely. 

So far as the size of these tympanic cysts is concerned, the largest that 
I have seen was so large as to completely conceal all the remaining half of 
the drum-membrane ; that is, it was as large as a medium-sized pea. In 
every case but one the posterior half of the drum-membrane alone was in- 
volved. Finally, in one of the four cases first described I was surprised to 
find that there was quite a large perforation in the anterior half of the mem- 
brana tympani, and that pus escaped freely through it. To explain this 
condition of things satisfactorily, one must assume that inflammatory adhe- 
sions had at some previous time shut off the posterior from the anterioi' 
half of the tympanic cavity, perhaps not entirely, but at least to such an ex- 
tent as to keep the fluid contents of the posterior half under great pressure. 

So far as the treatment is concerned, the most urgent indication, in the 
case of cysts that communicate with the middle ear, is to establish a very 
free opening in the diverticulum, and then to treat the case in the same way 
as we should a simple case of purulent inflammation of the middle ear. 

7. Deformities caused by both the acute and the chronic forms of purulent 
inflammation of the middle ear. — Even the very worst cases of purulent in- 
flammation of the middle ear will often heal, and cease thereafter to give 
the patient any annoyance beyond that caused by the impairment of his 
hearing. This symptom, however, often brings such patients to the physi- 
cian's office, and in this way we have opportunities of seeing a great variety 
of deformities. It would require considerable space to give anything like a 
full list of the numerous pathological pictures presented by the cases that 
belong in this category. I will therefore simply allude briefly to some of 
the more important ones. 

Calcareous deposits in the drum-membrane furnish good evidence that 
the middle ear has at some previous time been the seat of a purulent in- 



DISEASES OF THE EAE. 27l 

flammation. During the course of this inflammation aggregations of pus- 
cells are deposited between the layers of the membrana tympani, and in 
this position undergo, first, cheesy and then calcareous degeneration. Ac- 
cording to the original distribution of the pus-cells, there will ultimately be 
developed either a plate of calcareous material or a series of small calcare- 
ous spots. I have seen almost the entire area of the drum-membrane occu- 
pied by one or more calcareous plates. Of themselves these chalky depos- 
its in the drum-membrane exert very little influence upon the acuteness of 
the hearing. I have seen extensive chalky patches in the drum-membranes 
of individuals whose hearing was very acute. Their chief value lies in the 
evidence which they afford of a previous purulent inflammation of the mid- 
dle ear, and also in the light which they throw upon the nature of the 
lesions underlying certain cases of marked deafness. Such calcareous de- 
posits have been found, post-mortem, in the neighborhood of the stapedio- 
vestibular joint, a location where they may produce a high degree of dis- 
turbance in the mechanism of hearing. During a patient's lifetime we 
cannot inspect this particular region ; but if we find calcareous plates in 
the membrana tympani of a very deaf individual, would it not be natural 
to infer — in the absence of other satisfactory causes — that a similar chalky 
material has been deposited in the tissues surrounding the foot-plate of the 
stirrup ? 

A tough and thickened drum-membrane is sometimes left as a permanent 
sequela of an otitis media purulenta of long standing. Taken by itself, 
such a thickening of the drum-membrane cannot very greatly impair the 
power of hearing. As an evidence, however, of a general thickening of 
the mucous membrane lining the middle ear, it must be considered as an 
important lesion. 1 

Cicatrices, or incomplete reproductions of the drum-membrane sub- 
stance (as represented by its three essential layers), are very common. They 
are usually round, oval, or kidney-shaped, but they may also have other 
shapes. They are, as a rule, smooth, extremely thin, and transparent, and 
yield to pressure as if they were made of rubber. In a few cases we find 
the cicatrix in a crumpled condition, as if it had been unduly stretched. 
Anatomically such cicatrices consist of the dermoid layer, on the side 
toward the meatus, and of a continuation of the epithelial layer which con- 
stitutes the free surface of the tympanic mucous membrane. Between 
these will be found some elastic fibres and a few capillary blood-vessels, 
but probably no nerves. The significance of the existence of such cicatri- 
cial spots in the drum-membrane is simply this : they afford strong, if not 
absolutely positive, proof that at some previous time the middle ear has 
been inflamed, and that, as a result of such inflammation, a perforation of 

1 Urbantschitsch (Archiv fur Ohrenheilkunde, X., p. 7) describes peculiar pearl- 
like thickenings of the epithelium of the drum- membrane. 



272 DIAGNOSIS AND TREATMENT OF 

the same size as the cicatricial spot was established in the membrana tym- 
pani. After inflation, these cicatrices, unless the Eustachian tube happen 
to be unusually pervious to air, will be found to present a totally different 
appearance. In the place of a flat, or, more commonly, a concave, smooth, 
transparent surface, we shall see a tense, slightly opaque, hemispherical or 
tomato-shaped blebs, which in the course of a few minutes usually returns 
to its former flat or concave state. More than once I have ruptured such 
cicatricial reproductions of the membrana tympani, and have in the major- 
ity of instances seen no harmful results from such a rupture. In one case, 
however, the inflation produced pain and some impairment of the hearing. 
I must therefore dissent from the views expressed by Politzer in 1868. 1 I 
believe it is better to avoid rupturing these cicatricial portions, and espe- 
cially such as are found lying against the mucous membrane of the prom- 
ontory. In these particular cases there is some likelihood that adhesions 
may have formed between the cicatrix and the mucous membrane, and 
forcible inflation under such circumstances is quite sure not merely to rup- 
ture the adhesions (which may in certain cases be a desirable thing), but 
also to tear the mucous membrane and cause hemorrhage (which in the 
middle ear is never a desirable thing). 

So far as the size of these cicatricial reproductions of the membrana 
tympani is concerned, I may say that in this respect there is practically no 
limit to the reproductive powers of the membrane. The substantia pro- 
pria, it is true, seems to possess extremely little regenerative power. On 
the other hand, the dermoid and mucous surfaces possess this power to an 
amazing extent. In one of my cases exactly one-half of the drum was 
cicatricial, viz., the posterior half. The dividing line between the original 
membrane and that which had been reproduced was very sharply drawn. 
The elastic nature of this cicatricial half manifested itself in a striking 
manner when I made an incision in it, — the lips of the wound instantly 
gaping widely apart as the tissues were divided. In four other cases 
there was very clear evidence that the drum-membrane had been entirely 
reproduced. I will describe each of these cases in brief outlines. 

Case I. —The patient, a boy about twelve years of age, consulted me at 
the New York Eye and Ear Infirmary, on the 3d of May, 1871, for a slight 
general impairment of his hearing. On questioning Mm, I ascertained 
that from early childhood up to a recent date he had been subject to a dis- 
charge from both ears. On examination I found the left auditory canal 
normal. At the inner end of the canal the picture presented to the eye 
was as if the membrana tympani had been destroyed. On closer inspec- 
tion, however, I discovered that a very thin membranous structure dipped 
directly inward from the annulus tympanicus, and applied itself closely to 

1 Wiener med. Presse, 1868. 



DISEASES OF THE EAK. 273 

all the irregularities of surface of the inner wall of the tympanum. The 
tip of the handle of the hammer was firmly bound down to the tissues of 
the promontory. Behind it the long process of the anvil and the posterior 
arch of the stirrup were seen standing out in relief, but from their peculiar 
glistening aspect it was evident that they too were covered with the cica- 
tricial membrane. 

Case II. — The patient, a girl ten years of age, was brought by her mother 
to the Infirmary on the 23d of August, 1871. The history given was this : 
Five years previously the child had contracted a double otorrhcea, which 
lasted without interruption for about two years and then gradually ceased, 
leaving her with a moderate degree of deafness. On examination I found 
that the posterior half of the right drum-membrane consisted entirely of 
cicatricial tissue, while on the left side the appearances presented were 
almost precisely the same as those observed in the preceding case. 

In regard to both of the preceding cases the objection may be raised 
that the thin membranous structures, which I have described as repro- 
duced drum-membranes, may have been in reality atrophied drum-mem- 
branes, which, through some intercurrent inflammatory action, had con- 
tracted adhesions with the inner wall of the tympanum. I admit the 
possibility of such a series of pathological changes, and I also admit the 
fact that an atrophied dram-membrane may present to the naked eye pre- 
cisely the same appearances as a newly-produced membrane. I think, 
however, that of the two hypotheses mine is the more probable ; especially 
if we take into consideration the previous history of each of these cases, 
and if we remember that the reproduction of a substitute for a drum-mem- 
brane that has been entirely destroyed is now a well-established fact. 1 In 
the following two cases the evidence is certainly conclusive. 

Case m. — The patient, a strong healthy boy eight years of age, was 
brought to see me on the 3d of October, 1872. The history which his 
mother gave was this: Three or four years previously he had passed 
through an attack of scarlet fever, which left him with a discharge from 
the left ear, which had continued ever since. I examined the ear and 
found that the drum-membrane had been entirely destroyed, and that from 
the posterior and upper part of the tympanum a pedunculate growth sprang 
which partially filled the inner end of the meatus. I removed this growth 
with the snare, and treated the thickened spot of mucous membrane from 
which it grew, first with pure nitrate of silver (in the form of a bead), and 

1 See the report of such a case by Dr. H. N. Spencer, of St. Louis, in the Trans- 
actions of the American Otological Society for the year 1871. 
18 



274 DIAGNOSIS AND TREATMENT OF 

afterward with powdered burned alum. The right ear was perfectly nor- 
mal. 

On the 24th of October, the discharge having ceased and there being 
no evidence of a return of the growth, I dismissed the boy from active 
treatment. 

On the 19th of January, 1880, I had an opportunity of examining the 
patient's left ear again. He said that he had remained perfectly free from 
a discharge since 1872, and that the ear had given him no trouble beyond 
that due to the slight impairment of the hearing. To my surprise I found 
that a thin, dermoid membrane had grown from the rim that remained of 
the original membrane, and followed the inequalities of the inner wall of 
the tympanum in much the same manner as was observed in the preceding 
cases. 

Case IV. — The patient, a boy fifteen years of age, came to the New 
York Eye and Ear Infirmary on the 27th of May, 1874. He stated that 
two years previously he had had scarlet fever, and that it was followed by 
a discharge from both ears, which had continued without intermission up 
to that time. On examination I found the right external auditory canal 
filled with pus. I cleaned the parts thoroughly, and then ascertained that 
the drum-membrane had been destroyed, and that the mucous membrane 
of the tympanic cavity was almost everywhere in a granulating condition. 
No effort had been made to keep the deeper parts of the ear clean, and as 
a result the purulent secretion had become highly offensive, and was un- 
doubtedly extremely irritating to the mucous membrane of the middle ear. 
I saw the patient at irregular intervals and treated the case in the usual 
way. It was not, however, until during the latter part of October of that 
year that I finally succeeded in arresting the tendency, on the part of one 
or two spots in the tympanic mucous membrane, to develop granulation- 
tissue. 

On the 17th of Aprils 1875, I found that the gap which had previously 
existed between the plane of the annulus tympanicus and the inner wall 
of the tympanum had been filled in by a newly produced cicatricial mem- 
brane of a peculiar glistening appearance. My notes read as follows: 
"The handle of the hammer loses itself in the tissues of the promontory. 
The drum-membrane— or, rather, a dry cicatricial tissue— follows accurate- 
ly the entire background, spanning the cavity at two or three points, viz., 
high up posteriorly and opposite the mouth of the Eustachian tube, as a 
tense, creased membrane." 

False membranes or bands of adhesion are often encountered in the mid- 
dle ear. They must be considered as sequelae of an acute or chronic inflam- 
mation (generally purulent in character) of the middle ear. I will select 
a few examples of this pathological condition from my case-books. In one 



DISEASES OF THE EAR. 275 

case the description reads thus: "The drum-niembrane is entirely de- 
stroyed, with the exception of a narrow rim at the periphery. The hammer 
is drawn out of position, so that the neck and a part of the head are visible. 
Its handle is bound down to the long process of the anvil by adhesions." 
In a second case I found " a strong, isolated fibrous band running from the 
lower part of the tympanic ring (the posterior half of the membrane having 
been destroyed) to (possibly) the head of the stirrup." In a third case a 
band ran from the centre of the handle of the hammer forward and a little 
downward to some point in the vicinity of the mouth of the Eustachian 
tube. In a fourth case the drum-membrane was found either to have un- 
dergone a high degree of atrophy or to have been replaced by a cicatricial 
membrane, through which was distinctly seen a whitish band running 
almost directly upward from the tip of the handle of the hammer to the 
region of the stapedio-incudal joint. In a fifth case the rigidity of the han- 
dle of the hammer, as ascertained by pressing upon it with the end of the 
probe, justified the assumption that the high degree of deafness which ex- 
isted in this case was probably due to a similar anchylosis of the other 
joints, and particularly of the stapedio-vestibular joint. In a sixth case I 
found the hammer drawn completely out of its natural position and bound 
down by firm adhesions to the anterior wall of the auditory canal, or, at 
all events, to the anterior edge of the annulus tympanicus. Finally, in a 
seventh case I found one of the larger ossicles similarly bound down to 
the upper and posterior wall of the canal. It was so enveloped in firm 
cicatricial tissue that I was unable to distinguish accurately which of the 
two ossicles it was. 

The deformities which I have just enumerated are comparatively rare. 
Much more common are those adhesions which bind the handle of the ham- 
mer, or the drum-membrane, or both, to the opposite promontory. 

Double perforations in the drum-membrane proper are by no means com- 
mon. In one of my cases the two perforations occupied the lower half of 
the membrane. In two other cases two small perforations were found, one 
in the anterior inferior quadrant, the other in the posterior inferior qua- 
drant. In the fourth case my notes read as follows : " All that remains of the 
drum-membrane is a narrow bridge of tissues stretching from the tip of the 
handle of the hammer to the opposite portion of the sulcus tympanicus." 

Finally, ii the category of deformities, I might mention the destruction 
or expulsion of the ossicles. — It is a very common experience to find the han- 
dle of the hammer reduced to a mere knob in the vicinity of the short pro- 
cess. If the hammer has disappeared, we may be very confident that the 
anvil has gone with it ; for when the anvil loses the support of the hammer, 
it becomes a mere dangling body, having only two remaining supports and 
those comparatively feeble (the stapedio-incudal and the tympano-incudal 
articular ligaments). Unless extensive caries or necrosis of the petrous 
portion of the temporal bone exists, the stirrup seems to be able to main- 



276 DIAGNOSIS AND TREATMENT OF 

tain its position firmly in the fenestra ovalis. When it goes, or rather, when 
its foot-plate goes, the hearing-power also vanishes. This at least must be 
the rule, but that exceptions may occur will appear from the fact developed 
in the following case : 

The patient, a well-known physician in this city, about forty-five years 
of age and very deaf, consulted me on the 17th of October, 1879, on ac- 
count of a very distressing tinnitus. He said that during boyhood he had 
been subject to a discharge from both ears, and that on one occasion his 
mother had discovered in the discharge from the right ear the stirrup, in a 
perfect state of preservation. She put it into a box and kept it as a curi- 
osity. The doctor had himself seen this ossicle as recently as during 1877, 
and was positive that it was the stirrup and not one of the other ossicles. 
During recent years he had been entirely free from discharge, and at times 
heard fairly well. I tested his hearing and found that words loudly spoken 
were heard about equally well in both ears. He could distinguish words 
correctly, however, only at a distance of three or four feet. The sound of 
the tuning-fork, when placed upon the forehead, was referred by the patient 
to that region, and not to either ear ; when held near the ear, it was heard 
by him at a distance of about four inches, in both ears. Every trace of 
the drum-membrane, hammer, and anvil had vanished from both ears, and 
a thick and pale (fibrous) cicatricial tissue covered the entire background, 
the on]y decided depression being a niche at the tympanic orifice of the 
Eustachian tube. 

This is the only instance that I have met with in which the evidence 
was fairly conclusive that the expulsion of this most important ossicle had 
not wholly deprived the patient of the hearing-power in the ear thus maimed. 
Nature, we may assume, had in this instance probably provided a fibrous 
substitute for the foot-plate of the stirrup before the actual separation and 
expulsion of the ossicle took place. 

The question of treatment of these deformities of the middle ear may be 
dismissed in a very few words. Excision of the hammer, and attempts to 
render it mobile by the employment of a certain degree of force in cases 
where this ossicle has acquired a rigid, immovable position, do not com- 
mend themselves to my judgment. Operative interference in cases of adhe- 
sions between the membrana tympani and the mucous membrane of the 
promontory, or between the ossicles and some portion of the tympanum, 
may possibly in certain cases accomplish some good ; but I have not yet 
had the good fortune to encounter a case in which I felt in the slightest de- 
gree encouraged to undertake such operative interference. In cases of sim- 
ple perforation of the drum-membrane, where the discharge has ceased, I 
never make any attempt to cause the healing over of the opening by a cica- 
tricial membrane, the gain which might result therefrom being altogether 
too insignificant. There is one point, however, which should be borne in 



DISEASES OF THE EAR. 277 

mind with regard to these cases of simple perforation. I refer to the harm 
which sometimes comes from the introduction of water into the external 
auditory canal. It is almost sure to find its way into the tympanic cavity, 
and — the tympanic mucous membrane being in a comparatively healthy 
state — its presence there is apt to give rise to considerable irritation, and 
perhaps even to re-establish a subacute purulent inflammation of these parts. 
The removal of impacted cerumen from the external auditory canal by 
means of the syringe may, in cases such as we are considering, result in 
the production of an evil which in its turn may require considerable treat- 
ment. In cases, therefore, in which there are good grounds for suspecting 
the existence of a perforation in the drum-membrane (without otorrhoea), 
the syringe should not be used, if we can possibly dispense with it. The 
patient should also be cautioned about bathing in either salt or fresh water, 
without first protecting the affected ear against the entrance of water. 

So far as the symptom of deafness is concerned, a certain degree of re- 
lief may be obtained in a few cases by the wearing of Toynbee's artificial 
drum-membrane. I have not seen more than four or five cases in which 
this contrivance, or some substitute for it, materially increased the acute- 
ness of the patient's hearing. At the same time I must confess that my 
lack of faith in its efficacy has led me to test its virtues in comparatively 
few cases. Furthermore, the presence of such a foreign body in the mea- 
tus, and in close contact with the drum-membrane, or with the stump of 
the manubrium mallei, is very annoying to the great majority of patients. 



CHAPTEE VIII. 
FRACTURES OF THE TEMPORAL BONE. 

The subject of fractures of the temporal bone is generally considered to 
belong to the domain of general surgery, and it may therefore seem some- 
what strange to some of my readers that I should treat of it in a work de- 
voted to diseases of the ear. A fracture of the temporal bone, however, 
implies, almost necessarily, damage to some part of the middle ear or laby- 
rinth, and, in consequence of this, many of these cases of fracture, after 
leaving the surgical wards of our hospitals, come into the aurist's hands 
for the relief of a partial or total loss of the sense of hearing. My experi- 
ence with cases of this class is therefore necessarily one-sided. It does not 
extend to the fatal cases, nor does it cover the first stage of the illness, ex- 
cept in so far as the facts relating thereto can be learned from the patient 
or from his friends. The picture which I may be able to draw of this trau- 
matic affection must therefore depend for its value chiefly upon the degree 
to which it supplements those already drawn by surgical authors. 

By reason of certain peculiarities in the construction of the temporal 
bone, fractures that take place in it are apt to occur at certain spots, or 
along certain fixed lines, where the bone is weaker than at other points. 
These lines correspond with the lines of union of the three bony portions 
which together form the temporal bone, and which originally (in the foetus) 
were separate centres of development, viz., the squamous portion (together 
with the zygoma), the tympanic portion (annulus tympanicus), and the 
petrous portion (together with the mastoid process). Fractures at these 
points are perhaps, strictly speaking, simply diastases. There is a fourth 
region, however, where the bone is particularly weak, and where a genuine 
fracture is very apt to occur. I refer to the central portion of the pars pe- 
trosa, where the bone is hollowed out by a series of cavities (the meatus 
auditorius internus, the cochlea, the vestibule, and the semicircular canals), 
separated from each other by comparatively thin partitions of bone. 
Finally, the squamous and the mastoid portions of the temporal bone, sit- 
uated as they are upon the outer surface of the skull, are liable to be frac- 
tured or cracked at any point, viz., wherever the direct force of the blow 
or fall may be applied. Of the other fractures — viz., those occurring in the 
deeper parts of the temporal bone — a large proportion are undoubtedly 



DISEASES OF THE EAE. 279 

produced by contrecoup ; that is, in falling the patient strikes upon the 
back or top of his head, while the fracture occurs at the base of the 
skull. In the technical sense, however, I believe that the term " fracture 
by contrecoup " is applied only to those cases in which the direct force of 
the blow or fall is received upon the side opposite to that on which the frac- 
ture occurs. Aside from the treatment, the most practical question con- 
nected with fractures in this region is, how far can they be diagnosed at 
the bedside ? 

From a study of the fourteen cases which have come under my observa- 
tion, I find that I can make two grand subdivisions of fractures of the tem- 
poral bone, viz. : 

1. Fracture or diastasis of the tympanic or squamous portion in the re- 
gion of the middle ear, without implication of the petrous portion. 

2. Fracture of both the tympanic and the petrous portions. 

In one or two of these fourteen cases the symptoms observed seemed 
to justify the establishment of a third subdivision, viz. : fracture of the 
petrous portion of the temporal bone without implication of the middle 
ear. The chain of evidence, however, though pointing strongly to such a 
conclusion, is not sufficiently complete to warrant the introduction of this 
third class. 

Class I., which includes cases of fracture of the temporal bone in the 
region of the middle ear, without implication of the petrous portion, may 
be broken up into smaller subdivisions. Thus, for example, we may have : 

1. Cases in which no visible hemorrhage or other discharge takes place from 
the ear. 

2. Cases in which a hemorrlmge or bloody discharge from the ear follows 
the accident. 

3. Cases in which the accident is followed by spitting of blood, due to its 
escape from the middle ear, by way of the Eustachian tube, into the naso- 
pharyngeal cavity or nasal passages. 

Of the first subdivision I can give no examples. Of the second I can 
give two, as follows : 

Case I. — The patient, a carpenter, thirty-four years of age, was struck 
on the head by a falling plank, on the 1st of July, 1878. The blow ren- 
dered him unconscious only for a few minutes. He was then shortly after- 
ward able to resume his work, though not feeling right in his head. On 
the 8th of July he came to the Infirmary to obtain relief. He said that 
there had been a constant blood-stained, watery discharge from the left ear, 
and that the pain in his head had been steady and quite severe. He had 
noticed some impairment of the hearing on the left side, and a sensation 
of numbness on the forehead and on both sides of the face. He had also 
observed that when he exposed himself to the sun, and when he lifted heavy 
objects, the headache was much aggravated. His gait was perfectly steady. 



280 DIAGNOSIS AND TREATMENT OF 

On examination I found that there was still an oozing of bloody serum 
from the left ear, and that the hearing was so far impaired that the patient 
could hear the ticking of the watch only when it was pressed against the 
ear. The soft parts lying immediately above the drum-membrane were red 
and so much swollen that only the lower part of the membrane itself was 
visible. No perforation could be seen. 

(My notes contain no memoranda of the treatment adopted.) 
On the 31st of July the patient was seen a second time. He still com- 
plained a little of his head, but the discharge from the ear had ceased, 
and the hearing had been restored to almost its normal degree of acute- 
ness. 

During the following October the patient was seen a third time, and 
was found to be perfectly well in every respect. 

Case II. ^-Machinist (Bridgeport, Conn. ), fifty- two years of age, and well 
nourished. November 28, 1873. Sixteen days ago he received a blow on 
the right side of the head. It was followed immediately by profuse bleed- 
ing from the right ear, and partial unconsciousness. The bleeding con- 
tinued for eight days, during a part of which time he had daily chills, with 
fever, followed by sweating during the night. Tinnitus, total deafness, pain 
and dizziness were the other prominent symptoms. He does not remember 
having noticed any discharge from the ear after the bleeding ceased. On 
the second day the pain in the ear became quite severe, and continued with 
increasing severity up to the eighth day. Coughing and blowing the nose 
aggravated the pain. At first it was confined to the ear alone, but it soon 
extended to the parts behind and above the ear, and eventually to the en- 
tire right side of the head. A cough, which has now become very trouble- 
some, developed on the fifth day. It is associated with a profuse muco- 
purulent expectoration. The patient has had no distinct chills since three 
days ago. Chilly sensations and sweating, however, still continue. He 
complains of feebleness. He was positive that the hearing in both ears was 
perfect before he received the blow on the side of the head. During the 
past few days he has experienced an almost constant desire to sleep. (This 
symptom is very marked. The moment the man has finished answering 
my questions, and while I am writing my notes, he drops off into an appar- 
ently sound sleep, from which I am obliged to rouse him before putting a 
new question to him.) Face and neck noticeably congested. Veins on the 
forehead and temples stand out prominently. Pulse at wrist, 72 and feeble. 
Eespirations (counted while he was asleep in the chair), 28 to the minute, 
"Watch heard when firmly pressed against the ear. Vibrations of the tun- 
ing-fork are uniformly referred to the right ear. With the good ear closed 
the patient can distinguish correctly only now and then a word spoken 
loudly in close proximity to the right ear. No appreciable redness or 
swelling of the mastoid integuments. This region, however, and also the 



DISEASES OF THE EAR. 281 

temporal region, are both quite tender on pressure. Eustachian tube easily 
inflated. External auditory canal normal. Membrana tympani congested 
and oedematous ; no bulging. 

Under date of July 1, 1874, Dr. George F. Lewis, his physician, wrote 
that the patient gradually recovered his health, and was at that time per- 
fectly well. 

Finally, in the third subdivision of Class I., I would place the following 
case : 

Case m. — The patient, a female, twenty-five years of age and in good 
health, was seen by me at the New York Eye and Ear Infirmary, on the 15th 
of June, 1870. She gave the following history : Four days previously she fell, 
striking upon the left side of the head. Since then she had experienced 
moderately acute pain in the right ear, and constant noises, like the rush- 
ing of waters, but no appreciable deafness. On the day following the ac- 
cident she occasionally spat a little blood. On examination I found the 
right drum-membrane partially concealed by a bloody blebs, which pro- 
jected forward from the posterior and upper portion of the canal, at its 
line of junction with the membrana tympani. The drum-membrane itself 
— so much of it, at least, as was not concealed by the bloody tumor — pre- 
sented a purplish red appearance. There was tenderness on pressure both 
behind and in front of the ear. The watch was heard at a distance of six 
inches. Treatment : puncture of the blebs ; warm douche every half -hour 
until pain had been relieved. 

On the 18th of June she reported that a slight discharge from the right 
ear had made its appearance on the 16th. Pain steadily diminishing. 
Watch heard at a distance of only three inches. No perforation in the drum- 
membrane visible. 

On the 9th of July she reported that the discharge had ceased. On ex- 
amination I found that the membrana tympani had lost its red color, and 
presented simply an opaque appearance. External auditory canal normal. 
No pain. Patient simply complained of an unpleasant resonance of her 
own voice in the affected ear. Watch heard at a distance of twenty inches. 

August 3d. — Watch heard at a distance of six feet before inflation, and 
nine feet after it. 

In reference to these three cases, let me call attention to the fact that in 
all of them there were unmistakable evidences that some serious injury had 
been done to the parts immediately surrounding the drum-membrane, and 
yet in all of them the hearing was not seriously affected. For the present 
I will simply mention these two circumstances as constituting the promi- 
nent characteristics of cases belonging to Class I., or cases of fracture of 
some portion of the temporal bone in the immediate neighborhood of the 
drum-membrane. 



282 DIAGNOSIS AND TREATMENT OF 

Class II. comprises cases of fracture involving both the tympanic and 
the petrous portions of the temporal bone. These cases are, as a rule, of a 
more serious character than those belonging to Class I. The severity and 
duration of the illness which immediately follows the accident are usually 
so great that the aurist never sees such cases until after the characteristic 
lesions in the region of the drum-membrane have disappeared. The line 
or lines of fracture may run in a variety of directions, and may involve other 
organs besides that of the ear proper. From the symptoms produced by 
the accident, we may also, in many cases, locate more or less accurately the 
course pursued by the fracture. In illustration of this second class I will 
give here briefly the histories of ten cases : 

Case IV. — Eobert K., a liquor dealer, twenty-nine years of age, 'consulted 
me at the New York Eye and Ear Infirmary on the 23d of October, 1872, 
He gave the following history : Four weeks previously he fell from a wagon 
and struck upon his head. Blood flowed out of his right ear, as he was 
told, and he remained in an unconscious state for about twenty hours. 
When consciousness returned, he noticed that he was entirely deaf in the 
right ear. The objects in the room seemed to him to be going round in a 
circle. He vomited twice. For a period of nearly two weeks he was una- 
ble to go about without assistance, on account of the difficulty which he ex- 
perienced in maintaining his balance. Then, as improvement took place in 
this respect, he was able to walk about with the aid of only a cane. During 
the few days immediately preceding his visit to the Infirmary, he had been 
able to dispense with all assistance. At first the subjective sounds were of 
a musical character, but they gradually gave place to a simple ringing or 
roaring. On examination I found no lesions of any importance in the right 
ear ; the parts were practically in a normal condition. When the watch 
was pressed against the centre of his forehead he heard its ticking faintly 
in the left ear. (Treatment with iodide of potassium was advised, but the 
patient was not seen again. ) 

Case V. — Louis Anderson, a seaman, twenty-five years of age, was 
struck on the head by a falling heavy cable, on or about March 15, 1874 
He did not lose consciousness. As soon as he had recovered from the 
acute pain of the blow, he noticed that blood was running out of the right 
auditory canal, and that he could hear only with the left ear. He also dis- 
covered that he was unable to close the right eye ; and later, when he at- 
tempted to eat, he found that pieces of food lodged in the right side of the 
mouth, and that, in drinking water, some of it escaped from this same side. 
He was questioned with regard to his powers of tasting, but, so far as could 
be learned by mere questioning, his sense of taste had not been affected. 1 

1 Such a case of impairment of the sense of taste has been reported by Brunner : 
Archiv fur Ohrenheilkunde, Bd. V., p. 32. 



DISEASES OF THE EAE. 283 

Gradually all the symptoms disappeared, with the exception of the deaf- 
ness and a slight trace of the facial paralysis. Finding that the deafness 
persisted, the patient came to the Infirmary on the 29th of April, 1874. 

As the drum-membrane presented a perfectly normal appearance, and 
the facial paralysis was discoverable only upon careful search, I discouraged 
him from expecting any beneficial results from treatment. 

Case VI. — David Brant, a boatman, twenty- two years of age, fell, during 
the last week of January, 1874, a distance of about fifteen feet, striking 
upon his head. He remained in an unconscious state for about half an 
hour. During the following week there was a constant watery discharge 
from the right ear. Then the patient became very ill, the prominent symp- 
toms being pain in the head, fever, and delirium, with a continuation of the 
thin, watery discharge from the right ear. This acute illness lasted nearly 
two weeks, and from that time to the date of his visiting the Infirmary 
(March 28, 1874) he slowly but steadily regained his general health and 
strength. The discharge, which became decidedly purulent in character 
during convalescence, was still quite active at the time when he visited the 
Infirmary. On examination I found the right auditory canal filled with 
pus. The drum-membrane was perforated posteriorly, and its lower half, 
especially anteriorly, was converted into an irregular mass of granulation- 
tissue. So far as I could ascertain, the hearing-power had been totally de- 
stroyed in this right ear. When the watch was placed between his teeth 
in the median line, the patient said that he heard its ticking in his left ear. 

Treatment was commenced for the purpose of arresting the discharge, 
but the patient never returned. He was told that he would probably never 
recover the power of hearing in his right ear, and this undoubtedly drove 
him away from the institution. 

Case VH. — About the 1st of September, 1877, Michael Kennedy, a la- 
borer, forty years of age, fell from a scaffolding thirty feet high, and struck 
upon his head. He was found in an unconscious state, and remained so for 
two hours. For a period of two weeks and a half after the accident he was 
unable to leave his bed. During this time he was obliged to maintain a 
half-sitting posture, as whenever he attempted to lie down at full length the 
pain and distress in his head became unbearable. I was unable to learn 
exactly what his symptoms were during this period, or whether he had been 
delirious or not. He was quite sure, however, that no blood nor any wa- 
tery discharge had come from either ea 1 \ He remembered having been 
very much annoyed by a constant tinnitus, particularly in the left ear. 
Going upstairs or shaking his head, he said, aggravated the tinnitus very 
much. When he had so far recovered that he was able to leave his bed, 
he experienced great difficulty in maintaining his equihbrium. His head, 
he said, seemed to him as if it weighed a ton, and he felt all the time as if 



284 DIAGNOSIS AND TEEATMENT OF 

he were on the point of falling. This difficulty in walking did not materi- 
ally improve until about the middle of the following December. From that 
time to the 27th of December, when he made his first visit to the Infirm- 
ary, quite rapid improvement had taken place in this respect. At the time 
when I saw him he was able to walk fairly well ; there was no paralysis, but 
simply a lack of co-ordinating power. There was total loss of the sense of 
hearing in the left ear. Drum-membrane normal in texture and position. 
Hearing-power of the right ear nearly normal. (No treatment advised.) 

Case vTH. — The patient, a boy seven years of age, was brought by his 
mother to the Infirmary on the 8th of January, 1873. She stated that about 
six months previously he had passed through, first, scarlet fever, and then 
cerebro-spinal meningitis, which left him with a staggering gait. While 
in this condition he fell backward out of a wagon, and struck upon the 
back of his head. Inflammation of the brain set in, and, as a result of this, 
the boy became totally deaf. The mother, who was an intelligent woman, 
was positive that the deafness only developed after this accident, and not 
after either of the other illnesses. She was also confident that there had 
never been a discharge from either ear. On inspection I found both drum- 
membranes practically normal. 

Case IX. — John O'Brien, a boy twelve years of age, was knocked off 
the steps of an omnibus and fell, striking his head heavily against the 
pavement. He was taken up in an unconscious state, and was afterward 
" very ill " for several weeks. When he recovered, it was discovered that 
he had entirely lost the power of hearing in both ears. The parents state 
that there had never been any hemorrhage or discharge from the ears, and 
that the boy had not even complained of pain in them. On examination, 
December 6, 1873, a year after the occurrence of the accident, I found both 
drum-membranes perfectly healthy. 

Case X. — John Miller, a framer, fifty-eight years of age, came to the 
New York Eye and Ear Infirmary on the 29th of April, 1874. He said that 
in the spring of 1873 he fell a distance of eleven feet, striking upon his 
head. Blood flowed from both nostrils and ears. He was then " very ill 
for a long time," and in answer to my questions said that he had been out 
of his head part of the time. During recovery he found that he was al- 
most totally deaf ; at the same time he suffered from ringing noises in the 
head and from dizziness, and experienced considerable difficulty in swal- 
lowing. The deafness is still very marked (almost total), and he is not yet 
free from the other symptoms mentioned. Both drum-membranes are in- 
tact, though opaque and thickened. (No treatment advised.) 

Case XI. — Elenora Smith, a healthy girl, six years of age, was brought 
Iby her mother to the Infirmary on the 24th of July, 1872. The following 



DISEASES OF THE EAE. 285 

history was given : Three months previously the child fell down-stairs, and 
was ill for about a month with fever, delirium, and spasms. During re- 
covery the mother discovered that the child was perfectly deaf. She 
thinks that she made this discovery about ten days or two weeks after the 
occurrence of the accident, and at about the same time she noticed that 
there was a discharge from the left ear. The child's hearing previous to 
the accident had been perfect. When she was brought to the Infirmary 
her gait was still noticeably unsteady. The mother, whose attention was 
called to this peculiarity, said that it was then very much less than it had 
been during the early part of convalescence. On inspection, a simple 
otitis media purulenta, with perforation of the membrana tympani, was 
found on the left side, while on the right the middle ear appeared to be 
normal. 

Finally, to the foregoing cases, in which the injury was produced by a 
blow or a fall, may be added the following two, in which the impact of a 
bullet produced the injury : 

Case XII. — The patient, a powerful but idiotic-looking negro, thirty-five 
years of age, while animated by a desire to end his life, fired one chamber 
of a loaded revolver into his right ear, and then, finding that he was still 
alive, he discharged the contents of a second chamber into his left ear. 
This was done on the 6th of March, 1874, and on the 18th he was brought 
to the New York Eye and Ear Infirmary. I was not able to learn what 
had been the man's condition during the interval between these dates. 
The patient himself was perfectly deaf, and the person who accompanied 
him simply knew the facts relative to the shooting. On examination I 
found the right external auditory canal filled with polypoid granulations. 
These sprang from the anterior and lower wall of the meatus, about mid- 
way between the outer orifice and the drum-membrane. At this point the 
bent probe entered an excavation in which loose pieces of bone were en- 
countered. On the left side the auditory canal was also found to be filled 
with pus. I removed several small polypoid growths from the narrow canal, 
but failed to discover any region of exposed bone ; I also was unable to ob- 
tain a satisfactory view of the deeper parts of the canal. There could be very 
little doubt, however, of the absence of the drum-membrane, and probably 
of the ossicles. The right ear being very painful, I prescribed leeches. 

On the 22d of April I saw the patient a second time. The leeches had 
relieved him from pain. With the slender angular forceps I removed two 
fragments of bone from the right auditory canal. 

On the 2d, and again on the 6th of May, I removed fragments of bone, 
one of which presented a blackened appearance. 

On the 9th of May I encountered some hard substance in the region of 
the middle ear, and succeeded in extracting it. It proved to be a mass of 



286 DIAGNOSIS AND TREATMENT OF 

lead, about the size of a half-pea, probably a portion only of the ball fired 
from the revolver. The opening in the canal from which the fragments of 
bone had been removed presented every appearance of being on the point 
of healing. 

On the 16th of May I removed another piece of lead and some fragments 
of bone from the region of the right middle ear. 

On the 3d of June I found that the wound in the meatus had healed, 
and that the mucous membrane of the middle ear was free from all evi- 
dences of active irritation. The discharge had apparently ceased entirely. 

After the removal of the polypoid granulations from the left auditory 
canal all active discharge from that ear ceased. 

If the damage observed in this left ear is to be ascribed to the effects 
of the shooting, the bullet must have been extracted by some physician 
during the period of twelve days that elapsed between the infliction of the 
injury and the time of the patient's entrance into the Infirmary. 

In the preceding case it is quite possible that the squamous and petrous 
portions of the temporal bone (on both sides) were also fractured. The 
ball, however, may simply have driven the stirrup violently into the vesti- 
bule, and not have produced an actual fracture of the petrous bone. In 
the following case the petrous bone could scarcely have been involved to a 
serious extent, though probably the squamous portion did not wholly 
escape. 

Case XIII. — The patient, an apparently strong man, thirty-four years 
of age, and a soldier, was admitted to the New York Eye and Ear Infirmary, 
June 12, 1872. He gave the following history : In the course of an engage- 
ment with the enemy, in Valverde, New Mexico, on the 2 2d of February, 
1862, the company of which he was a member (Co. G., First U. S. Cavalry) 
was ordered to retake a battery. While they were advancing he was shot 
in the right side of the head, the ball entering the skin just in front of the 
ear. The shot had come from a detachment of the enemy in the rear. 
Three days later the ball was extracted from beneath the skin, just above 
the right eyebrow. He then noticed a sensation of throbbing and fulness 
in the right ear, and not long afterward a discharge made its appearance 
in 'the outer canal. He remembers also that one of his comrades, at about 
that time, removed a bunch of hair, clotted with blood, from the right ear. 
During the first ten or twelve months following the injury he frequently 
found small fragments of bone in the discharge from the ear. Six months 
previous to his visit to the Infirmary he had experienced a severe attack of 
pain in the right ear, but before that time he had always been compara- 
tively free from pain. From the very first he had been annoyed by a tin- 
nitus, like the roaring of a shell, All sounds, moreover, seemed to reach 



DISEASES OF THE EAR. 287 

him by way of the left ear. At night he had always been obliged to sleep 
on the right side, for whenever he attempted to lie on the left side the 
sense of weight in the right ear became unbearable. About a week previous 
to his visit to the Infirmary the parts about the right meatus became very 
painful and swollen. The swelling subsided in the course of a day or two, 
and then for the first time he discovered the presence of some hard sub- 
stance filling the outer canal. He came to the Infirmary for relief, and in 
this way became my patient. On examination of the ear I found a black 
mass,, partly covered by pus, blocking up the entrance to the right auditory 
canal. I experienced no difficulty in extracting it with the forceps, and 
on examination found it to be a very much corroded, oblong leaden bullet, 
a little over half an inch in length, and three-eighths of an inch in diameter. 
The deeper portion of the meatus was found to be filled with a mass of gran- 
ulations. No sinus could be found, nor any exposed surface of bone. The 
Eustachian tube was pervious. In front of the tragus there was a depressed 
scar, indicating the point where the other ball had entered. The patient 
was unable to hear the ticking of my watch in the right ear. The sound of 
a vibrating tuning-fork, placed on the central part of his forehead, was re- 
ferred by him to that point, and not to either ear. With the left ear 
tightly closed, and the right ear turned toward the speaker, he could un- 
derstand ordinary conversation at a distance of four or five feet. 

On the 15th of June the patient reported that he had been quite free 
from pain since the removal of the ball, and that the discharge had also 
ceased. 

On the 24th of July he again visited the Infirmary. The discharge had 
not returned. The tinnitus continued unchanged, but the sense of weight 
had disappeared, and he was able to lie indifferently on either side. Cica- 
trization had taken place in the ulcerated portion of the meatus, and there 
was then a clear but funnel-shaped passage down to the cavity of the 
tympanum. No trace was found of either the drum-membrane or the 
ossicles. 

At the time when he was wounded, and even up to the time when he 
visited the Infirmary, the patient supposed that his ear trouble had been 
caused by the glancing backward of a fragment of the ball which struck 
him in front of the ear. Even the removal of a tuft of hair from the exter- 
nal auditory canal had not suggested to him the idea of a second ball, until 
after I had shown to him that the leaden mass removed from the meatus 
could scarcely be considered as a fragment of the ball that had been ex- 
tracted from above the eyebrow of the same side. He then stated that 
many of the men in the enemy's ranks were armed with double-barrelled 
fowling-pieces, and suggested the possibility of his having been shot by the 
simultaneous discharge of both barrels of such a weapon. A more natural 
supposition is that he was shot by two balls contained in a single cartridge 
— one of them entering the meatus directly, without leaving any external 



288 DIAGNOSIS AND TBEATMENT OF 

wound, the other striking the bone in front of the ear and glancing for- 
ward. 1 

The complete loss of the hearing-power in all these eight cases (I ex- 
clude the last two) constitutes the distinguishing feature of this second 
class. When, in a case of injury to the head, this symptom is discovered 
shortly after the occurrence of the accident, it is safe to assume, with the 
knowledge which we at present possess, either that a fracture has taken 
place through the labyrinth, or that an extravasation of blood has taken 
place in the cochlea, without a fracture. The results of numerous post- 
mortem examinations show that fractures through the petrous portion of 
the temporal bone, involving the labyrinth, are quite common. We have, 
therefore, good grounds for assuming, in cases such as I have just de- 
scribed, that the total loss of hearing means a fracture of the petrous por- 
tion of the temporal bone. At the same time we do not possess a sufficient 
number of facts to justify us in excluding the possibility of a mere extrava- 
sation of blood without fracture. And yet, on the other hand, we possess 
no facts which show that the blood-vessels of the labyrinth are specially 
predisposed to rupture under the influence of a mere concussion. 

In this connection I should state that in one of my cases the hearing 
was not noticeably affected by the accident, but later, after meningitis had 
developed, the child became totally deaf. In this case, which I will narrate 
in brief outlines, the loss of hearing was undoubtedly due to an extension 
of the inflammation from the meninges to the labyrinth. 

Case XIV. — The patient, a boy eleven years of age and in fair general 
health, was brought to the Infirmary on August 6, 1872. According to the 
mother's statement, he had had a fall from a high stoop, on a Friday to- 
ward the end of April. After the fall he came home and said that he 
wanted to go to bed. Condition of hearing and equilibrium not then no- 
ticed. That night the mother observed that the boy moaned constantly 
through the night. The next morning, Saturday, he came down-stairs of 
his own accord, and then the mother noticed that his gait was staggering. 
That day the hearing was undoubtedly unaffected, inasmuch as the child 
answered all questions. That night he slept well. On Sunday morning 
he came down-stairs without assistance. Gait still staggering, though not 
so bad as on Saturday. On Sunday the mother noticed a change in his 
appearance ; his face was very pale, he vomited frequently, and complained 
of severe pain in the head. The vomiting ceased the same day, but the 
patient continued to complain of his head and gradually passed into a state 
of delirium and high fever. Acute symptoms with delirium and involun- 

1 For similar cases of gunshot wounds of the temporal bone, see Moos : Archives of 
Ophthalmology and Otology, Vol. IL, p. 342; Vol. III., pp. Ill and 216; Terrillon : 
Annales des maladies de Poreille, 1878, p. 249. 



DISEASES OE THE EAK. 289 

tary evacuations, continued for a little more than a week. Convalescence 
lasted four or five weeks. Staggering gait had continued up to the time 
when I saw him, but it was gradually growing better, as the mother 
thought. There had been no discharge from either ear at any time during 
his life. So far as I could discover, the deafness was absolute. On exami- 
nation I found both drum-membranes normal in appearance. I advised the 
parents to send the boy to some institution for deaf-mutes. 

In considering the significance to be attached to the different symptoms 
which are observed in cases of fracture of the temporal bone, we would natu- 
rally begin with that of bleeding from the ear. This symptom has always been 
considered of great diagnostic value. It was a prominent symptom in five 
of my cases. Prescott Hewett, in his article on Fractures of the Base of 
the Skull, 1 speaks of this symptom of bleeding from the ears in the follow- 
ing terms : " Bleeding from the ears, in severe injuries of the head, has, for 
many years past, been held, and deservedly too, as one of the most valuable 
diagnostic signs of fractured base. But this bleeding, to be of any value 
as a means of diagnosis, must be of a serious nature, and, above all, it 
must continue for some time. "With such a bleeding it may be safely diag- 
nosed that there is a fracture of the base running through the petrous 
bone,- and opening up a communication between the cavity of the tym- 
panum and some of the numerous and large vascular channels which sur- 
round this bone, or with an extravasation of blood within the cranium it- 
self." In the statement which I have just quoted, stress is laid, as will be 
observed, upon both the copiousness and the duration of the bleeding, and 
we are permitted to draw the inference that if the bleeding is not " of a 
serious nature," a fracture of the base may not have taken place. Again, 
in the next sentence, we are told that a copious and prolonged bleeding in- 
dicates the " opening up of a communication between the cavity of the 
tympanum and some of the numerous and large vascular channels which 
surround this bone, or with an extravasation of blood within the cranium 
itself." At this point let me state that neither Prescott Hewett's nor my 
own observations warrant any very positive statements on these }:>oints. 
This whole subject of fractures of the temporal bone needs to be studied 
afresh. We possess numerous good clinical observations made "by sur- 
geons ; we possess also the records of carefully made post-mortem exami- 
nations ; but we possess, so far as I know, no records of cases in which, in 
addition to the facts obtained by the foregoing methods of studying the 

1 Holmes' System of Surgery, VoL n., p. 284. 

■ The term " petrous bone " is used here. I suspect, not in the strict anatomical 
sense of the term, but rather with the idea of designating all that more solid portion 
of the temporal bone which lies below the line of the zygoma (viz., all of the petrous 
portion proper, a considerable part of the squamous portion, and the osseous auditory 
canal). 

19 



290 DIAGNOSIS AND TREATMENT OF 

phenomena of the disease, those obtainable by an examination of the audi- 
tory canal, membrana tympani, and middle ear, shortly after the occurrence 
of the accident, are available for purposes of study. I maintain that in 
every case of suspected fracture of the temporal bone, such an aural exami- 
nation should be made, and the conditions observed should form a part of 
the record of the case. Until this shall have been done in a sufficiently 
large number of cases, it will not be possible either to confirm or to refute 
authoritatively the statements which I have just quoted. So far as my own 
incomplete material furnishes any light upon the significance of bleeding 
from the ears, I may say that this symptom is susceptible of a somewhat 
broader interpretation than that given to it by Prescott Hewett. I would 
add to his proposition the following : When a fall or blow upon the head is 
followed by bleeding from the ear, no matter how trivial, we may diagnose a 
fracture of the temporal bone in the neighborhood of ShrapnelVs membrane, and 
probably in the line of the Glaserian fissure. By this proposition I mean to 
convey the idea that, so far as the mere symptom of bleeding from the ears 
is concerned, we are scarcely justified in assuming that the line of fracture 
extends beyond the region of the tympanum. The petrous bone may also 
be fractured at the same time, and a laceration of the lateral sinus, or of 
one of the smaller sinuses, may have taken place ; but the mere fact of a 
copious hemorrhage from the ear does not, in my opinion, justify us in as- 
suming the existence of any such serious lesions. In the first place, if we 
concede the possibility of a persistent and copious venous bleeding from 
the ear, we must assume that an almost gaping communication exists, first, 
between the middle ear and the venous sinus, and, second, between the 
middle ear and the external auditory canal. Otherwise, how could venous 
blood flow freely and copiously from one of the sinuses in the cranial cavity 
out into the external meatus ? I am far from denying the possibility of such 
an occurrence, and am even disposed to believe that the case of the machin- 
ist, Case I., may afford an example of this very combination of lesions. In 
the majority of cases, however, a fairly copious and protracted bleeding 
may occur from a simple laceration of the tympanic artery, such as would 
be very likely to follow a fracture involving the temporal bone in the line 
of the Glaserian fissure. As there are no other sources 1 besides the two 
mentioned, from which a copious hemorrhage in the meatus might come, 
we must choose between these in any given case. I have very little doubt 
that a careful examination of the drum-membrane alone, if made before 
these parts have become inflamed, would aid us very materially in deter- 
mining the source of the bleeding. 

The necessity of such examinations is shown very clearly in those cases 
of fracture in which no outwardly visible hemorrhage or other discharge 
takes place from the ear. As all my cases are cases of recovery, I am un- 

1 The carotid artery is, I believe, only very rarely lacerated in injuries of this kind. 



DISEASES OF THE EAR. 291 

able to furnish an indisputable instance of fracture of the temporal bone 
without hemorrhage from the ear ; but Dr. George L. Peabody, the patholo- 
gist of the New York Hospital, has very kindly supplied me with such an in- 
stance from the records of that institution. The report reads as follows : 

James Battersby, set. 40 ; Ireland, widower, iron-worker ; admitted 
June 2, 1879. About an hour before admission he fell from a scaffold while 
at work on the Ninth Avenue Elevated Railroad, a distance of twenty feet, /»**^jfe 
striking his head on the pavement. . .-••' - •*$ ' 

He was suffering from shock, from which he rallied after administr^"' 



of stimulants. On admission he was found in a condition of stupor, and 
was observed to be absolutely deaf. He could easily be roused, talked in- 
telligibly, and was not paralyzed at all. There was a slight contused wound 
of scalp, which did not reach the bone, and the history states that " exam- 
ination of surrounding parts gave no evidence of fracture." 

He took but little nourishment, became gradually completely comatose, 
and died on June 4th, two days after admission. There was a thin watery 
discharge froni the nose, but there were no aural signs except deafness. 
Before he died the scalp was incised, and a fracture detected. 

Autopsy 24 hours after death. — The viscera of thorax and abdomen were 
substantially normal. The following is the account of the examination of 
the head as taken from the autopsy book (Case 109) : 

Beneath dura mater is a thin coagulum, extending over convexity of 
cerebrum pretty generally. At anterior extremity of left frontal lobe there 
is a rather thick clot, which extends into brain-substance. Latter is com- 
pletely broken down, hemorrhage having probably taken place from vessels 
of brain-substance. Sphenoid lobe on same side is in similar condition, 
as is also posterior extremity of right hemisphere of cerebellum. Ventricles 
are normal, and in other respects brain is healthy. 

There are several fractures of skull, viz. : one beginning in occipital 
bone in fossa for cerebrum of left side, and extending downward to the 
right through interior occipital protuberance, and onward through the 
fossa for the cerebellum on right side, obliquely to foramen magnum, which 
it enters on the extreme right of its circumference. 

One on the right side, beginning in the foramen lacerum posterius and 
extending forward through the middle Of the petrous portion of the temporal 
bone, and terminating in the roof of the tympanum. By removing this, the 
ossicles are found enveloped in a small clot of blood. There is no appear- 
ance of hemorrhage in the mastoid cells. 

One on right side, starting at anterior condyloid foramen, and extend- 
ing upward and forward to foramen lacerum posterius. 

One on the left side, extending from the inferior maxillary foramen for- 
ward through the greater wing of the sphenoid to the foramen lacerum 
anterius. 



292 DIAGNOSIS AND TREATMENT OP 

One on the left side, through the petrous portion of the temporal bone, 
extending from the foramen lacerum posterius forward and inward through 
the roof of the tympanum, and onward to the inferior maxillary foramen, 
at which point it becomes continuous with the preceding fracture. On 
removing roof of tympanum ossicles are found as on other side, surrounded 
by a clot of blood. On this side there are clots in the mastoid cells. 

The membranse tympanorum are not affected, except that they show a 
slight bulging outward, caused by blood in tympani, as described above. 

On careful examination, it was found that the fractures in both temporal 
bones extended into the semi-circular canals, and that on the right side the 
cochlea contained a clot. The right Eustachian tube is filled with clotted 
blood. 

The symptom of visible bleeding from the ears is not, therefore, a neces- 
sary accompaniment of a fracture of the temporal bone. On the other 
hand, evidence of inflammation of the parts surrounding the drum-mem- 
brane affords excellent evidence of such a fracture. 

Of the remaining symptoms, which may be ascertained without an ex- 
amination of the drum-membrane, the most important, after hemorrhage 
from the ear, is that of a watery discharge from the external auditory canal. 
The significance of this symptom has, I think, been very fairly stated by 
Prescott Hewett in the article to which I have already made reference. 1 He 
sums up the matter in these words : " There are, then, as far as is known 
at present, three classes of cases of this watery discharge. In the first class, 
where the fluid from the ear is plentiful and of a decidedly watery character 
immediately after the accident, there need be no doubt as to the nature of 
the injury — the watery discharge is due to the escape of the cerebro-spinal 
fluid, which, as already stated, can only take place through a fracture of the 
petrous bone implicating the internal auditory canal and its membranes. 

" In the second class of cases, characterized by a copious and prolonged 
bleeding from the ear, followed by a watery discharge, a fracture of the 
petrous bone may also be safely diagnosed ; but it cannot be said that the 
fracture follows any particular course. In these cases it must, however, be 
clearly understood that it is not to the watery discharge that we can trust 
for our diagnosis, but to the copious and prolonged bleeding. 

"Thus far there is no difficulty. Not so, however, in the third class of 
cases, in which there is at first a discharge of blood only, neither copious 
nor prolonged, which is followed by a watery discharge, varying as to the 
time of its appearance — varying as to its quantity. It may be present within 
a very few hours after the accident — it may be profuse within a few hours 
after its appearance. These are the cases in which experience has of late 
proved that the diagnosis ought to be doubtful. The discharge of blood 



Op. cit., Vol. II., pp. 291 and 292. 



DISEASES OF THE EAE. 293 

is certainly not of a character to wan-ant a diagnosis of fracture of the 
petrous bone ; and as to the watery discharge, it is now well known that 
such a discharge may occur within a few hours after the accident, that its 
quantity may even be profuse, and yet there may be no fracture." 

Among my own cases there are but two in which the symptom of a 
watery discharge from the ear was well marked. In one of these a blood- 
stained watery discharge made its appearance soon after the accident, and 
continued for at least a week afterward. As the hearing was almost entirely 
restored in this case, it is safe to assume that the fracture did not involve 
the petrous portion of the temporal bone, but merely the tympanic or the 
squamous portion. The watery discharge was therefore probably purely 
inflammatory in its nature. In the other case a watery discharge was ob- 
served shortly after the. occurrence of the accident, and continued for at 
least a week. Inflammation of the meninges then set in, and the discharge 
soon became purulent. As the hearing-power was totally destroyed in the 
affected ear, it is probable that the fracture involved the petrous as well as 
the tympanic portion of the temporal bone, and that the watery discharge 
was due largely, at first, to the escape of the cerebro-spinal fluid. In this 
connection, however, I should mention a fact with which every aural sur- 
geon is familiar, and which should make us hesitate a long time before we 
pronounce a watery discharge, no matter how profuse, to be due to the es- 
cape of the cerebro-spinal fluid. The fact to which I refer is this : in ex- 
ceptional cases of acute inflammation of the middle ear the flow of a thin 
serous fluid from that cavity, after a perforation has become established in 
the drum-membrane — whether by natural or by artificial means, it matters 
not — is so copious as to excite very great astonishment. I have known it to 
soak through several cloths in the course of a night, and to give place to a 
distinctly purulent discharge only after two or three days had elapsed. 
Furthermore, the breaking of the bony wall of the tympanum and the con- 
sequent laceration of the superjacent soft parts would supply an amply 
adequate exciting cause for such a high degree of irritation of the tympanic 
mucous membrane as this profuse watery discharge would imply. 

Once more I desire to call attention to the question of examining the 
ears of patients supposed to be suffering with fracture of the temporal 
bone. The lesions demonstrable by the aid of the speculum and reflected light, 
in the soft parts immediately surrounding ShrapnelVs membrane, furnish us 
with a valuable means of locating at least a part of the injury done to the tem- 
poral bone. If a fracture or diastasis has occurred in the line of the Glas- 
erian fissure, we should find either an actual solution of continuity in the 
soft parts, or a 'spot from which blood is escaping ; or, if one or two days 
have elapsed since the occurrence of the accident, we should not fail to find 
well-marked evidences of inflammation in the vicinity of ShrapnelTs mem- 
brane, or along the anterior portion of the upper wall of the bony canal. 
The rent in the soft parts may even involve the drum-membrane proper. 



294 DIAGNOSIS AND TREATMENT OF 

On the other hand, all evidences of this local inflammation may disappear 
as early as during the fourth week following the accident. 

In this connection the question naturally suggests itself, why may not 
the inflammation of Shrapnell's region, or the escape of blood from some 
point in this vicinity, or even an actual rent in the soft parts, owe its origin 
to something else besides a fracture or diastasis of the neighboring bone ? 
In the light of this question let us examine some of these cases of assumed 
fracture in the neighborhood of the middle ear. For example, in the second 
case narrated above, the patient received a blow on the right side of the 
head, and the hemorrhage took place from the auditory canal of the same 
side. In this case, therefore, the hemorrhage might possibly have come 
from some superficial blood-vessel which had been ruptured by the violent 
concussion of the air in the auditory canal. In the first case, however, this 
explanation would be considered, to say the least, far-fetched. The man 
was struck on the top of his head by a falling plank, and blood escaped 
from one ear. In the third case the patient fell and struck upon the 
left side of the head, but her symptoms thenceforth all pointed to some 
serious damage done to the opposite ear, and inspection, four days Later, 
showed it to be the seat of two significant lesions — inflammation of the 
parts near Shrapnell's membrane, and an extravasation of blood in the mid- 
dle ear. In both of these cases there can certainly be no question of a vio- 
lent concussion of the air in the auditory canal, and we are obliged to seek 
for some other cause. A fracture of the bone near Shrapnell's membrane, 
affords, as it appears to me, the only satisfactory explanation of all the 
phenomena observed. A fracture of the bone in this particular locality, 
where the soft parts are tense and inelastic, means, at the same time, a rup- 
ture of these soft parts. If the fracture follows the line of the Glaserian 
fissure, — and in many of the cases this is probably the course which the 
fracture takes, — we have a right to expect that in a certain proportion of 
them the tympanic artery, which lies in that fissure, will be torn. The 
copious bleeding from the ears, which is so often observed in these cases 
of fracture of the base, owes it origin, I believe, quite as frequently to the 
tearing of this artery as to the laceration of one of the more remotely situ- 
ated venous sinuses. An artery that is surrounded by bony walls is more 
likely, when ruptured, to bleed for an unusually long time, than one whose 
muscular coats have an opportunity to contract and retract. 

Thus far I have considered only those symptoms and visible lesions 
which point to fractures in two parts of the temporal bone, viz., the petrous 
portion and the tympanic portion. There are other symptoms, however, 
which enable us to still further define the course which the fracture may 
have taken. Thus, for example, in one of my cases there was facial paraly- 
sis on the same side as that on which the hearing-power had been destroyed. 
It was discovered shortly after the occurrence of the accident, before in- 
flammation could have set in, and was undoubtedly due to the direct effects 



DISEASES OF THE EAE. 295 

of the violence. The simplest explanation would be that the line of frac- 
ture involved the facial canal, which lies just above the oval window (see cut 
on p. 361). l In another case the patient experienced considerable difficulty 
in swallowing. Without more accurate data than those which my notes of the 
case furnish, I can scarcely express an opinion upon the significance of this 
symptom. In a case of fracture of the base, recently seen by Dr. L. Putzel, of 
this city, the patient made precisely this same complaint; and, on closer scru- 
tiny, the doctor discovered that the difficulty experienced was not in swallow- 
ing, but in masticating the food taken into the mouth. The masseter and 
temporal muscles of one side were paralyzed, and the patient was unable to 
protrude the lower jaw straight forward. The inference which he drew 
from this condition was, that the fracture had not merely involved the cen- 
tral portion of the pars petrosa (the patient had entirely lost the hearing in 
one ear), but had probably extended down to the very apex of the bone, 
causing injury to motor filaments of the fifth nerve. Finally, in the second 
case mentioned above, the combination of symptoms points, I believe, to a 
fracture not merely involving the tympanic or the squamous portion of the 
temporal bone, but extending probably through the posterior wall of the 
tympanum down to the lateral sinus, and perhaps even causing a rent in its 
walls. The daily chills, fever, and sweating ; the development of a cough 
on the fifth day, and the profuse muco-purulent expectoration which soon 
became associated with it ; the flushed face, prominent veins of the head 
and neck, and marked stupor ; perhaps, also, the tenderness on pressure 
in the mastoid region — all these symptoms, it appears to me, are to be ex- 
plained upon the assumption that a fracture, involving the fossa sigmoidea, 
caused a phlebitis of the lateral sinus, and this in turn gave rise to the 
pyaemic manifestations, and then to those of interference with the venous 
circulation (drowsiness and fulness of the veins). 

It is a great mistake, it seems to me, to think that nothing is to be 
gained by an examination of the ears, in such cases, beyond the establish- 
ment of the diagnosis upon a somewhat firmer basis. The first examina- 
tion will, as a matter of course, accomplish this result, but subsequent ex- 
aminations, if made at proper intervals, should in many cases enable the 
surgeon to materially modify the severity of the inflammation which is al- 
most certain to follow the violence done to the parts lying along the base 
of the brain. The timely establishment of a free opening in the membrana 
tympani, incisions in the inflamed and tense tissues in the neighborhood 
of Shrapnell's membrane, the free use of leeches and the warm douche — 
are not all these measures just as likely to be efficacious in a traumatic in- 
flammation of the middle ear as in one of different origin ? and may not the 
abatement of the inflammation in this limited area be sufficient to turn the 
scale in favor of recovery ? 

1 Consult Eysell: Archiv fur Ohrenheilkunde, Bd. VII., p. 208. 



CHAPTER IX. 

DISEASES OF THE MASTOID PKOCESS. 

Anatomy. 



At birth the mastoid process consists of a small, flattened tuberosity, 
containing but one cell of considerable size — the antrum (see Fig. 21). At 
puberty there is a distinct prominence, conical in shape, whose apex points 
downward, and whose length, in some instances, may measure as much as 
an inch and a quarter (Figs. 23 and 24). The substance of this bony prom- 
inence is formed of a number of small cavities, or 
cells, varying very greatly in size and shape. Some 
of these cells communicate with one another, and 
are lined with an extension of the mucous mem- 
brane of the tympanum. Others are simply filled 
with a fatty tissue resembling that which is found 
in the cliploe of fresh bones. Zuckerkandl, 1 who 
examined one hundred mastoid processes in the 
fresh state, and one hundred and fifty macerated 
specimens, found that air-cavities were wholly lack- 
ing in twenty per cent, of the specimens, and that 
perfectly pneumatic mastoid processes, without any 
diploetic spaces, represented only 38.6 per cent, 
of the entire number. Furthermore, he ascertain- 
ed the fact that in some individuals only the lower 

half of the process is diploetic, while the upper half is pneumatic. These 
comparatively recent researches 2 throw a great deal of light upon the path- 
ology of acute and chronic purulent affections of the middle ear, and it is 
not so very improbable that the facts which they have established may even 
lead to the discovery of better methods of diagnosis. 




A — Hj 



2B.~ 



Fig. 21. — A vertical tranverse 
section through mastoid portion 
of an infantile temporal bone: 
d — dura mater ; A = antrum ; 
to = rudimentary mastoid pro- 
cess. (Natural size.) 



1 Monatsschrift fur Ohrenheilkunde, Bd. XIII., No. 4. 

2 Schwartze (Arch. f. Ohr., June, 1873, p. 169) makes the statement that, accord- 
ing to Zoja, diploetic spaces are often found in the mastoid process, near its apex and 
on the median (inner) side. This is the earliest reference to the subject that I can 
find. 



DISEASES OF THE EAR, 



297 



Such marked differences have been found in the size of the air-cells, in 
their limits of distribution, in the thickness of the bony partitions which 
separate them one from another, and in the thickness of the layer of bone 
which forms the outer side of the mastoid process, that no general state- 
ment can be made with regard to these points. If, in an individual who 
has not been subject to a chronic purulent inflammation of the middle ear, 
the process stands out very prominently from the side of the head, we may 
assume that the pneumatic spaces are well-developed, and that the outer- 
most ones he very near the surface. This was the case in the specimen 
represented in Fig. 24. The apex itself of the bone consisted of a single 
large cavity, in the upper and inner portion of which I counted three broad 
openings leading into adjacent cells. Above this cavity lay a series of 




Fig. 22.— Mastoid process of a child (get. cir- 
ca 5), with well-developed air-cells or pneumatic 
spaces. Same section and lettering as in Fig. 
21. (Natural size.) 




~JL 



Fig. 23.— Mastoid process at puberty. Same section 
and lettering as in Fig. 21. (Natural size.) 



smaller cells, in each one of which I found at least one opening that com- 
municated with an adjacent cavity. Anteriorly, as will be seen in the cut, 
the pneumatic cells extend into that part of the temporal bone which con- 
stitutes the upper wall of the external meatus. Superiorly, they extend to 
within half an inch of the temporo-parietal suture. Posteriorly, they cease 
abruptly, and without any appreciable diminntion in size, in the immediate 
vicinity of the temporo-occipital suture. In Schwartze's article (loc cit.), 
the statement is made that Hyrtl, out of six hundred skulls examined by 
him for this purpose, found three in which the pneumatic cells extended 
even into the occipital bone. Farther on (p. 351) will be found the history 
of a case of large abscess of the mastoid process, in which pus was also 
found between the outer and inner tables of the occipital bone, a short dis- 
tance back of the temporo-occipital suture. At the time of the operation, 
I supposed that the pus occupied the diploetic spaces natural to this region. 



298 



DIAGNOSIS AND TKEATMENT OF 



In the light of Hyrtl's discovery, however, it appears probable that the pus 
really occupied pneumatic spaces. 

In the specimen which I have just described (Fig*. 24), the external table 
of the bone measured scarcely a millimetre in diameter. Usually, however, 
in drilling into the bone from the outside, we do not reach the cell-structure 
at such a slight depth. The thickness of the outer layer of solid bone 
varies, I should say, from one to three millimetres. 

In the distribution of its pneumatic cells, the temporal bone from which 
Fig. 24 was taken, must not be considered as an average type, but rather as 
an exception. The relations depicted in Fig. 23 more nearly represent the 
average cell distribution in the human adult mastoid process. 

At the posterior and upper portion of the tympanic cavity is the en- 
trance to the mastoid antrum, or " horizontal portion of the mastoid cells," 
as it is termed by Toynbee. In macerated specimens this entrance is com- 




Fig. 24. — Mastoid process. External portion chiselled away to show how far the cells extend. 

paratively broad, but in the natural condition of the parts, and especially 
when the mucous membrane is swollen from inflammation, it is a rather 
small opening. In the adult the antrum occupies a position from 12 to 20 
mm. (J-f in.) distant from the outer surface of the bone. In cases of 
hyperostosis, it is sometimes situated at a greater distance from the outer 
surface of the bone. It is separated from the dura mater by a plate of 
bone which rarely exceeds one millimetre in thickness, and as a rule is 
probably thinner than this. The posterior extremity of the antrum is sep- 
arated from the lateral sinus by an interval of cell-structure which varies 
from three to five or six millimetres in thickness. 



DISEASES OF THE EAE. 299 

Finally, there are several points where the bone surrounding the antrum 
is pierced by small channels which give passage to blood and lymph ves- 
sels. The two most important of these are : 1, the sutura petro-squamosa, 
and 2, the channels for the mastoid emissary veins. One of the latter 
often opens on the outer surface of the mastoid process, near its centre, 
and about on a level with the upper wall of the external auditory canal. 
It is along the first of these channels that inflammation spreads from the 
antrum to the intracranial organs, and along the second that it reaches the 
subcutaneous cellular tissue on the side of the neck. The mastoid inflam- 
mation may also set up a phlebitis of one of these emissary veins and so 
lead to phlebitis and perhaps thrombosis of the lateral sinus, with which 
it directly communicates. 

Pathology. 

It is not my intention to undertake in this place a thorough exposition 
of the pathology of mastoid diseases, but simply to mention briefly certain 
points which seem to me to have an important bearing upon the diagnosis 
and treatment of these affections. Thus, for example, I think it is desir- 
able to keep clearly before our minds the idea that in both the acute and the 
chronic forms of mastoid disease, obstruction to the escape of the products of 
inflammation from the antrum is almost invariably the cause of those changes 
or processes which endanger the patient's life. It is therefore a very rare thing 
to meet with a case of serious disease of the mastoid process in an ear 
whose membrana tympani has been destroyed ; and when we do encounter 
such cases, we may look confidently for the presence of obstructive granula- 
tions at the tympanic orifice of the antrum. 

In the second place, it must be remembered that in individuals who 
have been subject to a chronic purulent inflammation of the middle ear, 
the pneumatic spaces in the mastoid process may become completely oblit- 
erated through a process of sclerosis or hyperostosis. We are familiar with 
such a process of hyperostosis in the middle ear proper, and I can see no 
good reason why we should not accept the doctrine that the ivory-like hard- 
ness of the mastoid process, which we often encounter in operations upon 
that bone, is due, at least in a certain proportion of the cases, to an actual 
hyperostosis, and that this, in turn, owes its existence to a chronic subacute 
inflammation of the mucous membrane lining the pneumatic cells. I may 
also add that in chronic purulent inflammation of the middle ear, such a 
subacute inflammation of the mucous membrane lining the pneumatic cells 
is probably the rule. To test the correctness of this view, I have carefully 
examined the histories of Schwartze's fifty cases of perforation of the mas- 
toid process (with drills or with gouges). In twenty-three out of the fifty 
a chronic purulent inflammation of the middle ear, of not less than five 
years' duration, preceded the acute symptoms which induced Dr. Schwartze 



300 DIAGNOSIS AND TREATMENT OF 

to perform the operation of perforating the mastoid process ; and in thir- 
teen of this number, — 56|- per cent., — complete or nearly complete sclerosis 
of the middle and upper portions of the process was found. Of the re- 
maining ten cases there are four in which no mention whatever is made of 
the condition of the bone, and six in which it is distinctly stated that there 
was no sclerosis. In these six cases, however, it is quite possible that scle- 
rosis of the mastoid process, or at least of that portion of it which is ordi- 
narily exposed to view by the operation, could not have taken place, simply 
because these parts had already, during the earlier stages of the disease 
(perhaps even years before the operation was performed), been destroyed 
by carious processes. Out of five cases of my own, which were similar to 
Schwartze's twenty-three cases, there were four, — or 80 per cent., — in which 
more or less pronounced sclerosis of the mastoid process was found at the 
time of the operation or on post-mortem examination. In the light of the 
evidence afforded by Schwartze's and my cases, therefore, we may establish 
the following rule : The existence of a sclerosed condition of the mastoid pro- 
cess may be assumed in the great majority of cases of chronic purulent inflam- 
mation of the middle ear. 

The facts established by Zuckerkandl's researches, make it easy for us 
to understand how a large abscess may develop in the mastoid process in a 
comparatively short period of time. We have only to assume that this 
bony prominence is perfectly pneumatic, and there is then no difficulty in 
understanding how, if the inflammation of the middle ear be allowed to go 
on unchecked for a certain period of time, these large and freely intercom- 
municating pneumatic cells may become filled with pus, and how, later, 
under the influence of ulcerative processes, the bony septa between the cells 
may undergo disintegration, thus converting the entire bony prominence 
into an abscess imprisoned in a shell of bone. 



General Clinical History. 

Inflammation of the mastoid process is characterized by a great variety 
of symptoms, according to the duration and degree of severity of the in- 
flammation, the part or parts of the organ implicated, and the extent to 
which it has involved neighboring organs. In accordance with the anato- 
mical limits of the inflammation, we may distinguish three classes of mas- 
toid affections, viz. : 1, those in which the antrum is the part chiefly in- 
volved ; 2, those in which the surrounding body of the bone participates 
in the inflammation to an equal or decided degree ; and 3, those in which 
the prominent feature of the disease is a periostitis of the outer aspect of 
the bone. There are no sharply drawn boundary lines between these three 
classes, nor are they in any sense separate and distinct affections. There 
are practical reasons, however, why we should endeavor, in each case of 



DISEASES OE THE EAE. 301 

supposed mastoid disease, to assign it to its appropriate place in one of the 
three classes mentioned. 



I. Affections in which the Antrum is the Part chiefly Involved. 

In all the inflammatory affections of the middle ear the antrum, which 
may be considered as a mere diverticulum of the tympanic cavity, must al- 
most necessarily participate. In the great majority of cases, there are no 
symptoms which call our attention in the slightest degree to this particular 
portion of the middle ear. In a few, however, the antrum becomes the seat 
of pathological changes which call for special therapeutic measures, and 
which may even assume such prominence as to render the original disease 
of the tympanic cavity of decidedly subordinate importance. 

Probably the simplest form of clinically recognizable antrum disease is 
that to which may be given the name of 

Chronic subacute purulent inflammation. — In the treatment of the great 
majority of simple, uncomplicated cases of chronic purulent inflammation 
of the middle ear, little or no thought, I suspect, is given by physicians to 
the antrum, as a locality which may need separate attention. So far as my 
own practice is concerned, I have, up to a recent date, entirely ignored this 
portion of the middle ear, at least in the class of cases to which I have just 
referred. At the same time I have often been puzzled to know why, in so 
many cases, in which apparently all the conditions were favorable to success, 
my efforts to arrest the discharge should have proved fruitless. I had 
searched carefully for some concealed spot of caries of the bony walls of the 
tympanum or for some granulating point in its lining mucous membrane, 
but had failed (in these particular cases) to find any such cause for the per- 
sistent otorrhcea. It then occurred to my mind that possibly the discharge 
might come in large part from the antrum, and that treatment directed 
more especially to this cavity would result in the complete arrest of the 
discharge. I soon had an opportunity of subjecting this view to a practical 
test. Three cases of chronic purulent inflammation of the middle ear were 
placed under my care for treatment at nearly the same time. In all three 
of them the pathological conditions were almost precisely the same. In 
the first case the patient was an adult, forty-five years of age ; in the other 
two, the patients were respectively twelve and fourteen years of age. All 
of them were in good health, so far as I could judge. In the case of the 
adult there had been no discharge from the ear for a period of several 
years. Recently, however, without any known reason, the discharge had 
reappeared, and at the time when he consulted me it had been going on 
for a period of several weeks. In the second case the discharge had ex- 
isted for about one year, the child having contracted the disease during 
an attack of scarlet fever. In the third case the discharge had existed 
(though not continuously) for a period of several years. In all three cases 



302 DIAGNOSIS AND TREATMENT OF 

the membrana tyinpani was practically destroyed, and in all three the mu- 
cous membrane of the inner wall of the tympanum was very much swollen. 
In addition to this diffuse swelling of the mucous membrane, there was in 
each case a circumscribed growth of granulation-tissue, located just behind 
the promontory in two cases, and just above the centre of it in the third 
case. The entrance to the antrum in the latter case was so contracted that 
I could barely introduce the tip of the middle-ear pipette into it. In the 
other cases the entrance appeared to be of natural size. In all three cases 
I assumed that the irritation which had caused the swelling of the mucous 
membrane of the inner tympanic wall, was supplied by the secretions from 
the antrum. The treatment adopted was in brief the following : first, the 
removal of the masses of granulation-tissue in the tympanum with the 
snare ; second, cauterization of the remaining raw surface with a bead of 
nitrate of silver ; third, the washing out of the mastoid antrum with luke- 
warm water ; fourth, the injection into that cavity of a two-grain solution of 
nitrate of silver ; fifth, the application of powdered burned alum and iodo- 
form in small masses to all that portion of the tympanic mucous membrane 
which was visible. The first two steps were found necessary only at the 
first visit. The remaining steps were carried out at each succeeding visit. 
In two out of the three cases the discharge was entirely arrested after the 
fifth or sixth visit. In the third case it was arrested still earlier, but it re- 
turned very slightly after the lapse of a few days, and the case is still under 
treatment. This last case is the one in which the entrance to the antrum 
is very much contracted. In this case I also observed that the water which 
escaped from the antrum after washing it out, was quite milky in appear- 
ance. 

The evidence afforded by these cases is, I fully appreciate, susceptible of 
a different interpretation from that which I am disposed to adopt. Thus, 
for example, the objection may be raised, that the arrest of the discharge 
was due to the restoration of the tympanic mucous membrane proper to a 
fairly healthy condition, by means of those remedial measures which were 
directed particularly to that portion of the middle ear, and not to any im- 
provement in the condition of the mucous membrane of the antrum that 
may have been brought about by the measures directed especially to that 
locality. To this objection I would reply that, in one of the cases, I at 
first paid no attention whatever to the condition of the antrum, and failed 
to secure as the result of my strictly tympanic treatment, more than a di- 
minution in the activity of the discharge ; while in the same case, a few 
months later, I experienced no difficulty, by treating the antrum in the 
manner already mentioned, in very soon arresting the discharge perma- 
nently. I cannot help feeling that in the other two cases also the antrum 
treatment had a great deal to do with the promptly favorable results ob- 
tained. 

When I have had more experience in this (to me) new plan of manag- 



DISEASES OF THE EAR. 303 

ing a certain class of cases of chronic purulent inflammation of the mid- 
dle ear, I may be able to speak more positively with regard to the pro- 
priety of conceding a certain degree of individuality to such a chronic 
subacute purulent inflammation of the mastoid antrum. In the meantime, 
however, I would urge those of my colleagues who are in the habit of treat- 
ing cases of chronic purulent inflammation of the middle ear, to adopt 
special antrum measures in those instances in which the disease seems to 
resist all the ordinary methods of treatment, and in which there are no 
demonstrable lesions of a sufficiently pronounced character to explain the 
obstinacy of the discharge. 

Before dismissing this subject I will give a brief account of a case 
which I saw in 1872, and which I even at that time was disposed to con- 
sider as belonging to the form of disease which I am now considering. 

Case I. — The patient, a rather pale medical student, but yet in fairly 
good health, consulted me in March, 1872, for an otorrhoea of fifteen 
years' standing. It had established itself as a sequela of scarlet fever, and 
was accompanied by constant tinnitus and by frequent attacks of a dull, 
steady pain, referred to the deeper parts of the ear. Various methods of 
treatment had been pursued, but the discharge had never materially di- 
minished. An inspection of the ear showed the membrana tympani to have 
been entirely destroyed, the handle of the hammer resting against the 
promontory, the mucous membrane being pale and very fibrous in appear- 
ance, and the posterior upper portion of the tympanic cavity being filled with 
a small mass of granulations which seemed to grow from the entrance to the 
antrum. There was no tenderness over the mastoid process. The watch 
could be heard at a distance of 7 inches. A few applications of chromic 
acid were made, and the granulations shrank entirely out of sight behind 
the projecting angle of bone. 

The subsequent treatment consisted in introducing a probe, armed 
with cotton, thoroughly cleansing and drying all the parts within reach, 
and then applying nitrate of silver in solution (the strength being gradu- 
ally increased from twenty grains to a drachm to the ounce of water). At 
the expiration of two weeks the discharge was just as abundant as at the 
first. On the 29th of March, I substituted powdered alum for the silver 
solution, blowing it in with a suitable tube. The quantity used was just 
sufficient to form a thin layer over the exposed mucous membrane. On 
the 30th the patient reported that there had been almost no discharge since 
the last application. The alum was accordingly applied a second time, 
after all the remains of the first charge had been removed. This sec- 
ond application was followed in the course of an hour by dizziness, nausea 
and vomiting, and a throbbing sensation in the ear, without tinnitus. Ob- 
jects appeared blurred before his eyes. Two hours afterward he had a 
second similar attack, which compelled him to take to his bed. The dizzi- 



304 DIAGNOSIS AND TREATMENT OF 

ness and nausea continued then for nearly forty-eight hours, when the dis- 
charge reappeared, and he was again able to walk about. 

In view of the long continuance of the discharge, of the frequent, dull, 
deep-seated pain, of the presence of granulations which sprang from the 
entrance to the antrum, and from the throbbing sensation which ensued, 
when that entrance became closed, — as it doubtless did when the alum was 
applied, — it appeared to me probable that the case was one of chronic sub- 
acute purulent inflammation of that cavity. 

Acute inflammation, probably without caries. — In all cases of acute inflam- 
mation of the middle ear the antrum undoubtedly participates in the in- 
flammatory process to as great a degree as does the tympanic cavity proper. 
In this sense, therefore, acute inflammation of the antrum may be said to 
be a very common affection. The clinical picture presented under these 
circumstances, however, is the familiar one of an acute inflammation of the 
middle ear, and the distinctive participation of the antrum is only recogniz- 
able in exceptional cases. Thus, for example, in the following cases, the 
evidence showed conclusively that the mastoid region was participating to 
more than the usual degree in the general inflammation of the middle ear. 
The only element of doubt relates to the question whether, among the 
component parts of the mastoid process, the antrum alone was involved, or 
whether the surrounding pneumatic spaces were not also, and to an equal 
extent, inflamed. Pain in the mastoid region and over the corresponding 
side of the head, redness and swelling of the upper and posterior wall of 
the meatus in the immediate neighborhood of the membrana tympani, only 
slight tenderness on pressure over the mastoid process, and particularly 
over its upper portion, and no noticeable redness or swelling of the mas- 
toid integuments, these are the symptoms which, as it appears to me, would 
justify us in drawing the conclusion that the inflammation was still restricted 
chiefly to the mastoid antrum. 

Case II. — The patient, a man seventy years of age, in good general 
health, came to the Infirmary on the 3d of November, 1873. He said that 
about six weeks previously he began to suffer from pain and deafness in the 
right ear. Two weeks later a discharge made its appearance, but the pain 
continued with but little if any abatement. On examination I found the 
meatus filled with pus. The upper portion of the drum-membrane was 
red and swollen, and presented an appearance of pouting ; elsewhere it 
exhibited a very tough appearance. I made a free incision through the 
posterior half of the membrane, and also through the posterior fold, and 
prescribed the use of the warm douche at home. 

November 5th. — Pain still continues, but it is decidedly less severe. 

November 8th. — Discharge has ceased. Pain is now referred only to 
the mastoid region, where there is tenderness on pressure, but no redness 
or swelling of the skin. Four leeches to be applied over the spot of great- 



DISEASES OF THE EAE. 305 

est tenderness, which corresponds to the point of entrance of the principal 
mastoid emissary vein. 

November 12th. — Dull pain still continues in the mastoid region. Tinc- 
ture of iodine to be applied daily to the painful locality. The membrana 
tympani still retains a red and swollen appearance, but there has been no 
discharge for nearly a week past. 

November 15th. — Persistent dull pain in mastoid region. No percepti- 
ble benefit from the iodine. Mastoid integuments freely incised, and the 
sides of the wound thoroughly cauterized with nitrate of silver, after the 
bleeding had entirely ceased. 

November 19th. — External wound suppurating freely. Pain almost 
entirely relieved. 

November 22d. — Wound healing rapidly. Patient complains now only 
of a roaring sound in his ear. (He was not seen again.) 

Case HI.— Female, thirty-two years of age and in robust health, she 
was attacked with an influenza on the 9th of November, 1872, and had more 
or less fever, with a constant catarrh of the eyes and nose. On the 12th, 
the right ear became involved, the symptoms being moderate deafness, 
roaring and some pain. Watch heard at a distance of six inches. Exter- 
nal auditory canal healthy. Membrana tympani dull, opaque, and rather 
flatter than normal. The air during inflation entered the middle ear with 
a dry sound. Four leeches applied in front of the ear. 

November 14th. — The leeches afforded only partial relief. Membrana 
tympani (edematous in appearance and somewhat convex outwardly. 

November 15th. — Patient passed a bad night. The pain is again severe, 
and is referred by her to the entire side of the head. Tenderness on pres- 
sure over the mastoid process, but no redness or swelling of the integu- 
ments. The posterior wall of the external auditory canal has also become 
tender upon pressure. A free vertical incision through the posterior half 
of the membrane was followed by an oozing of bloody serum from the 
wound. By inflation of the middle ear through the Eustachian catheter 
the serum was made to escape in such quantity that it ran down over her 
cheek. 

November 16th. — Comparatively free from pain last night. The water- 
ery discharge continued through the night, as shown by the stains on the 
pillow. The tenderness has disappeared, and patient feels quite well again. 
No subsequent return of the pain. 

Case IV. — Female, about thirty-five years of age, and of a rather delicate 
constitution. January 20, 1877. Two days ago, while suffering from a 
bad "cold in the head," and not very long after snuffing salt water for 
the relief of her trouble, she was seized with a rather sharp pain in the 
right ear. Yesterday, the pain in the meantime having grown worse, five 
20 



306 DIAGNOSIS AND TREATMENT OF 

leeches were applied behind the ear. These afforded only temporary relief, 
and, as a consequence, she was able to get but little sleep during the night. 
To-day the pain has been severe. On examination with the speculum and 
reflected light, the membrana tympani, and especially the upper and poste- 
rior portion, is found to be red and swollen. Two small blebs, springing 
from the lower wall of the canal, conceal the lower part of the drum-mem- 
brane from view. Incision of posterior half of the membrane afforded 
escape to a drop of bloody serum. Warm douche to be used freely. Pa- 
tient to remain in bed. 

January 21st. — She has passed another night of suffering. There is now 
a free sero-purulent discharge, but the pain has not abated. On examina- 
tion the posterior wall of the meatus is found to be greatly swollen in the 
vicinity of the drum-membrane. Tenderness over the mastoid process, but 
no redness or swelling of the integuments. Patient being under the influ- 
ence of ether, two free incisions were made through the inflamed tissues of 
the external auditory canal and posterior fold of the drum-membrane, and 
a third through the mastoid integuments. Tent introduced into the exter- 
ternal wound. Poultices to be applied, and patient to be given 10 minims 
of Magendie's solution of the sulphate of morphia. 

January 22d. — She passed a fairly comfortable night, and to-day feels 
comparatively free from pain. Tent removed. 

January 23d. — Pain again moderately severe. The discharge from the 
ear is now decidedly purulent. Pulse, 104 ; temperature, 99.2° F. 

January 24th. — Pain still persists throughout the entire right side of the 
head, and is especially noticeable whenever she coughs. 

January 25th. — Last evening pain again became quite severe. Tempera- 
ture rose to a little over 100° F. Four leeches were applied in front of the 
tragus. This morning patient feels better. The discharge is now profuse. 
Temperature normal. Patient is conscious of a constant escape of pus 
through the Eustachian tube into the back part of the nose. From the 
character of the matter expectorated (absence of mucus) and from the sen- 
sations experienced by the patient, I have very little doubt that the dis- 
charge referred to comes from the middle ear by way of the Eustachian 
tube. Swelling of inner end of meatus diminishing. 

January 26th. — Continued improvement. Temperature, normal ; pulse, 
88. Tubal discharge diminishing ; discharge from the meatus still active. 

February 3d. — Patient is now entirely free from pain, and there is very 
little discharge from the ear. 

February 14th. — The perforation in the drum-niembrane has healed, and 
very little swelling of the parts remains. An insignificant scar indicates 
the location of the incision behind the ear. Watch heard at a distance of 
4 inches. 

In children an acute inflammation of the antrum may lead, in a compara- 



DISEASES OF THE EAR. 307 

tively short time, to inflammation of the coverings of the brain. The fol- 
lowing case may serve as an illustration. 

Case V.— The patient, a girl, six years of age, and of apparently delicate 
constitution, was seen by me for the first time on January 4, 1876. About 
four weeks previously she had passed through a rather severe attack of 
pharyngeal diphtheria, from which she had scarcely recovered, when she 
began, about one week previously, to complain of pain in both ears. The 
pain, which soon became severe, had continued with unabated severity up 
to the time when I saw her, robbing her of sleep and of all desire to take 
nourishment. On the day when I was asked to see her she had been a 
little delirious at times. Temperature, 105° F. ; pulse, 140. The deaf- 
ness seemed to be almost total. Examination with the speculum and re- 
flected light showed the right drum-membrane to be red and swollen in its 
upper portions, and somewhat bulging superiorly and posteriorly ; the parts 
were perfectly dry. On the left side the external meatus was partly filled 
with masses of whitish moist epithelium. The druin-niembrane was red 
and swollen. There was no redness, swelling, or tenderness of the mastoid 
integuments on either side. I made a free incision through the posterior 
half of each membrana tympani. Only blood was evacuated by the incision. 
"Warm douche to be used freely, also poultices. 

January 5th. — No improvement. Temperature, 105° F. ; pulse, 140, and 
feeble ; sordes on teeth ; tongue dry ; no discharge from either ear. Child 
lies as if in a state of partial coma. At the suggestion of Drs. Markoe and 
James It. Wood, who were called in to see the child, mercury was adminis- 
tered : internally, in the form of calomel, in small doses ; externally, in the 
form of inunctions of the oleate of mercury (10 per cent.), frequently re- 
peated. Bromide of potassium was also given, in conjunction with the cal- 
omel. 

January 6th. — Yesterday the child was decidedly delirious, especially 
toward night, and cried out, at intervals, with pain (referred to the left ear 
chiefly). This morning, however, the child is very much better, an active 
discharge having established itself in both ears during the night. 

From this time onward, — as I learned from her physician, Dr. A. A. 
Davis, — she made a rapid recovery, and regained her hearing almost per- 
fectly. 

In the four preceding cases I am disposed to believe that the inflamma- 
tion at no time involved the pneumatic cells to any considerable extent. In 
the case last narrated (Case V.) the inflammation extended to the coverings 
of the brain — probably by way of the blood-vessels and other soft parts that 
pass from the antrum to the cranial cavity through the fissura petro-squa- 
mosa, and this complication for a short time completely overshadowed the 
original disease. The mastoid pneumatic spaces may have been imperfectly 



308 DIAGNOSIS AND TREATMENT OP 

developed, in this case, and so have offered an obstacle to the extension of 
the inflammation in an outward direction ; or the vascular connections be- 
tween the dura mater and the mucous membrane of the antrum may have 
been more numerous than they usually are, and so have favored the spread 
of the inflammation from the latter cavity to the meninges. In adults, the 
inflammation is apt to travel from the antrum proper, or from the series of 
pneumatic spaces immediately surrounding it, along the central emissary 
vein to the outer integuments. Pus may also find an outlet through this 
channel, and in this way sometimes a spontaneous cure may be effected. 
In the following four cases I think it is reasonably clear that the antrum 
was the part chiefly affected, and that the pus eventually found a way for 
itself, not through the intervening pneumatic or diploetic spaces, which 
probably participated in the inflammation in only a subordinate degree, but 
along the bony channel normally occupied by the mastoid emissary vein. 

Case VI. — (New York Eye and Ear Infirmary.) "Wm. B. Hillison, set. 
forty-five, janitor, previously in good health. (Patient seen in consultation 
with Dr. Charles Laight.) In August, 1872, he overheated himself, and 
then sat in a draught of cool air. A few hours later, he experienced severe 
shooting pains in the right ear, and a throbbing sensation in the mastoid 
region. The pain continued, with varying severity, for ten days. At the 
end of this time a discharge appeared, and was soon followed by relief from 
pain. Early in November the discharge ceased, and the pain again became 
severe. This time it was referred chiefly to the region behind the ear, and 
was accompanied by some tenderness and swelling of the parts. The swell- 
ing gradually increased, and on December 14th he reluctantly decided 
to seek medical advice. His physician, Dr. Charles Laight, found the 
meatus swollen, and the mastoid region these at of quite a large swelling. 
A free incision through the mastoid integuments liberated about an ounce 
of healthy pus. No denuded bone detected. 

December 15th. — Pain relieved. A profuse sweat to-day. 

December 16th. — Mastoid region again moderately painful. Wound 
healing by adhesion. Occasional pain in the right chest. 

December 18th. — To-day I saw the patient for the first time, in con- 
sultation with Dr. Laight. The pain again severe. The countenance pale. 
Pulse 108, and feeble. Holds his head as if suffering from a stiff neck. 
The skin and subjacent tissues over lower portion of mastoid process, and 
extending at least two inches below it, are soldered by inflammation into a 
single, flattened, hard mass, red on the surface. Tenderness on pressure, 
extending up toward squamous portion of temporal bone. Meatus very 
much swollen, and filled with fetid pus. A small mass of granulations on 
posterior superior wall of meatus, just beyond the junction of the cartilagi- 
nous with the osseous portion. From this point a sinus leads to exposed 
but apparently not carious bone. Deeper parts of the meatus not recog- 



DISEASES OF THE EAR. 309 

nizable. Perforation of the mastoid process advised, and patient recom- 
mended to enter the New York Eye and Ear Infirmary. The operation was 
performed the same afternoon by Dr. Laight. The perforation was made 
with a drill, which was applied at a point half an inch behind the meatus, 
a little below the level of the upper wall, and was directed inward, decided- 
ly forward, and a little upward. The instrument first encountered cell- 
structure at a depth of three-fifths of an inch. No pus. Ordered decubi- 
tus, poultices, generous diet, iron and quinine, and sherry wine, f vi. daily. 

December 19th. — Almost entire relief from pain. Pulse 90, and stronger 
than yesterday. Meatus still swollen. Takes food well. 

December 20th. — Free discharge from the wound and from the meatus. 
Steady improvement. The wound and the meatus both to be syringed fre- 
quently with a weak solution of carbolic acid. 

January 18, 1873. — The wound has entirely healed except at one point, 
where a small sinus leads to the perforation in the bone. The sinus in the 
meatus has also closed. Since the 8th of January there has been no dis- 
charge from the meatus. A small perforation still present in the membrana 
tympani. General condition greatly improved. No return of pain since 
the operation. 

January 29th. — Patient is to-day discharged cured. 

Case VIL — Male, twenty-one years of age, in good general health (New 
York Eye and Ear Infirmary), November 3, 1875. About three months ago 
he contracted a severe earache in the left ear from bathing in salt water. 
The pain continued to be severe for a period of two weeks, and then became 
bearable. About six weeks ago the pain again returned and has continued 
with, on the whole, increasing severity up to the present time. Besides 
the pain and deafness he has noticed a roaring sound in the affected ear, 
but never any discharge. The pain now involves the entire side of the 
head. On examination, I find the inner half of the meatus filled with a 
dark-colored material looking like a mixture of cerumen and pus. There 
is no appreciable redness or swelling of any part of the canal. The drum- 
membrane is covered with a tough, whitish material — undoubtedly a soaked 
and thickened layer of epithelium — which completely conceals the outlines 
of the hammer. A V-shaped incision was then made in the membrane, but 
it was not followed by any escape of fluid. By lifting up the flap, it was 
observed that the middle ear was filled with a semi-gelatinous substance 
(see page 205), which very soon, however, became infiltrated with blood. 
Nothing abnormal observed in the region of the mastoid process. 

November 6th. — Since last note there has been a constant discharge 
from the left ear. To-day, for the first time, the pain has been appreciably 
less severe than usual. 

November 17th. — During the past few days there has been no discharge 
from the ear. The parts behind the ear, however, have become tender and 



310 DIAGNOSIS AND TREATMENT OF 

swollen. ' On examination I find the external auditory canal dry, and the 
perforation in the drum-membrane healed. The membrane has a tough, 
leathery appearance, and there are no evidences of inflammatory action in 
the immediate vicinity. The swelling behind the ear is found, on exami- 
nation, to be due to the presence of a collection of fluid beneath the skin. 
Fluctuation can be felt not only behind the ear, but also above it. A free 
incision affords escape to quite a large quantity of pus, and the probe re- 
veals the fact that it lay, at least in part, between the periosteum and the 
bone. While exploring the denuded bone surface, I discovered an opening, 
just large enough to admit the probe, at a point about an inch and three- 
quarters immediately above the tip of the mastoid process. The direction 
of the opening was upward, inward, and a little backward, and the probe 
passed into this bony canal a distance of half an inch without encoun- 
tering any resistance. A fresh tent to be introduced into the wound 
daily. 

November 20th. — Entire relief from pain since abscess was opened. 
Wound healing rapidly. Almost no tenderness in the vicinity. (No fur- 
ther data.) 

Case VDI. — Male, forty-two years of age and in good general health. 
May 17, 1879. (Case seen in consultation with Dr. E. T. Ely and afterward 
with Dr. Roosa.) Six days previously patient first began to suffer from a 
sensation of fulness and pain in the right ear. Dr. Roosa examined the 
ear and found the membrana tympani moderately inflamed. Two leeches 
were applied, but only temporary relief was afforded. As the pain con- 
tinued to increase, Dr. Roosa incised the membrane. The relief lasted but 
a short time, and leeches were again applied. All these measures having 
failed, the warm douche was tried faithfully. The pain, however, has gone 
on steadily increasing during the past three days, until now it is very se- 
vere. On examination to-day (in consultation with Dr. Ely, who has taken 
charge of the case during Dr. Roosa's absence), the drum-membrane is 
found to be red and greatly swollen. The neighboring cutaneous walls of 
the meatus are also very much inflamed, and almost entirely conceal the 
membrana tympani from view. The parts are slightly moist. There is no 
tenderness over the mastoid process. The patient being under the in- 
fluence of ether, the membrana tympani was punctured at its centre, and 
the incision was carried directly backward until the knife encountered the 
bone ; the incision was then extended outward, a distance of fully one-third 
of an inch, through the swollen tissues of the canal, the point of the knife 
being kept in contact with the bone throughout. A free escape of blood 
followed the incision, but no pus was observed. Eive leeches ordered ; 
four to be applied in front of the ear, and one behind. Warm douche to 
be used freely. 

May 18th. — During the night, after the free use of the warm douche, 



DISEASES OF THE EAR. 311 

an active purulent discharge set in, and the patient began at once to ex- 
perience relief from pain. This morning he feels decidedly better. 

May 19th.— Patient passed a comfortable day yesterday, but toward 
night he again experienced pain in the ear and right side of the head, 
though in a much milder form. To-day he feels quite free from pain. The 
discharge continues to be abundant. 

May 20th. — Yesterday afternoon the pain returned with all its previous 
severity. Temperature (beneath the tongue) was 101° F. ; pulse, 92. 
Three leeches were applied behind the ear, close to the auricle, and the 
after-bleeding was allowed to continue for some time after the leeches had 
fallen off. After a hot foot-bath had been given to the patient, he fell asleep 
and slept through the entire night. This morning his temperature is 98.8° 
F. He is very low-spirited about his condition, but expresses himself as 
being free from pain. Ordered two compound cathartic pills, his bowels 
being sluggish. 

May 21st, evening.— At 8 p.m. last evening, patient's temperature was 
100° F. He had taken his food well, and had been free from pain. As 
the compound cathartic pills had failed to accomplish their purpose, he was 
ordered to take four grains of blue pill that same evening and a full dose 
of Hunyadi Janos water the following (this) morning. To-day, with the 
exception of a short attack during the afternoon, he has been quite free 
from pain. Two copious movements of the bowels have taken place. The 
swelling of the inner end of the canal is as marked as it was on the 17th. 
and the discharge is still profuse. Temperature, 99.5° F. 

May 22d, evening. — This morning, the pain having again become severe, 
two leeches were applied behind, and one in front of, the ear. These af- 
forded only temporary relief. This evening the pain is again severe. It 
shoots, as he describes it, from between the occiput and the mastoid pro- 
cess, up over the side of the head. Temperature, 99.5 U F. Tenderness on 
pressure over the region situated just behind the mastoid process. Blister 
to be applied to this spot. Patient now takes, for the relief of his pain, a 
twelfth of a grain of sulphate of morphia every three or four hours. 

May 23d. — Patient passed a fair night, but to-day the pain is again se- 
vere. Discharge from the ear continues to be active, and the swollen con- 
dition of the drum-membrane and meatus does not abate. There is de- 
cided oedema, to-day, of the skin covering the mastoid process. Tempera- 
ture, 99.5° F. Pulse, 86. Magendie's solution of morphine, ten minims, 
to be given hypodermically, to relieve the pain. 

May 24th. — Patient passed a comfortable night ; morphine being now 
administered as often as is necessary for the purpose of relieving pain. 
Tenderness on pressure over the mastoid process is more decided to-day. 
Temperature normal. 

In view of the persistence and increasing severity of the pain, notwith- 
standing the vigorous antiphlogistic measures employed ; of the profuse- 



312 DIAGNOSIS AND TREATMENT OP 

ness of the otorrhcea, indicating the activity and extent of the inflamma- 
tion ; of the persistent swollen condition of the inner end of the meatus ; 
of the recent development of tenderness and oedema of the mastoid integu- 
ments ; and, finally, of the danger in which the patient would be placed, if 
the inflammation should continue to extend unchecked ; — in view of all 
these facts, and of the safety of the operation, I suggested to Dr. Ely the 
desirability of obtaining the patient's consent to having the mastoid pro- 
cess perforated at an early day. The doctor explained the matter fully to 
the patient, — himself a physician, — and, at the latter's request, Dr. C. R 
Agnew was asked to see him and pass judgment upon the propriety of per- 
forming the operation. Dr. Agnew examined the case carefully, and ex- 
pressed the opinion that the proper time had not yet come for the oper- 
ation. Dr. Koosa, who had by this time returned from a brief sojourn in 
the country, also concurred in this opinion, but favored a free incision of 
the skin and periosteum of the mastoid process. Such an incision was ac- 
cordingly made on the following day, May 25th. The bone at the bottom 
of the wound was found to be perfectly sound, so far as we could discover. 
Dr. Koosa now resumed charge of the case. 

On the 16th of June I again visited the patient, and learned that the 
incision of the mastoid integuments had afforded only temporary relief. On 
the 27th and 28th of May, quinine was given in large doses (70 grains in 
the course of the two days), in the belief that the pain might be of a neu- 
ralgic (malarial) character. The patient, it appears, had quite recently 
experienced a very severe attack of facial neuralgia, and this fact gave some 
color of probability to the view that a neuralgic element complicated the 
present illness. The quinine treatment, however, afforded no relief, and it 
was abandoned. On the 7th of June, as I was informed, the pain which 
had previously been referred to the entire right side of the head, as well as 
to the ear and its immediate neighborhood, localized itself chiefly just be- 
low the mastoid process. Coincidently with this change, right facial paral- 
ysis manifested itself (upper eyelid and the side of the mouth involved), 
and a well-defined swelling appeared just below the mastoid process. The 
power of the right side of the tongue to distinguish between bitter, sweet, 
acid, and salty, had not — as I was told — been affected. On examination, I 
find, just beneath the mastoid process, a flat, hard swelling, consisting evi- 
dently of diffusely inflamed connective tissue and cervical lymphatic glands 
matted together into an irregularly shaped mass. The skin covering these 
parts and the lower portion of the mastoid process is moderately congested. 
The discharge from the ear continues to be abundant. The improvement, 
which had begun already two or three days before, simultaneously with the 
development of the characteristic swelling on the side of the neck, con- 
tinued steadily from that time onward. The discharge from the ear very 
soon ceased, the patient's strength gradually returned, and he was soon 
able to leave the city for his summer vacation in the country. 



DISEASES OF THE EAR. 313 

At the present time (August 15, 1879) paresis of the facial still con- 
tinues, but it is much less noticeable than before he went into the 
country. (Shortly afterward every trace of the disease disappeared.) 

In each of the preceding seven cases the acute inflammation developed 
in a middle ear whose membrana tympani was probably at the time intact. 
In each of the following cases the inflammation seems to have developed in 
an ear whose drum-membrane was undoubtedly at the time defective. It 
is difficult to explain satisfactorily the progress of the disease in these cases, 
unless we assume that at an early stage of the inflammation the tympanic ori- 
fice of the antrum became closed. 

Case IX.— Dr. A. P. W., of Chester, S. C, set. 56, of a strong constitu- 
tion, consulted me, October 12, 1872, for a painful affection of the mastoid 
process. He gave the following history : In 1835 he contracted an acute in- 
flammation of the left middle ear from the bursting of a gun-barrel. The 
severe symptoms soon passed off, but the purulent discharge continued for 
some time afterward. Since that time, however, the ear has not troubled 
him in any way, except that there has been a moderate degree of deafness 
and some tinnitus. The perforation in the membrane has always persisted. 
About the middle of last July he noticed a slight serous discharge from the 
left ear, and felt a little pain in it. The pain became gradually more se- 
vere and was associated with headache and fever. The doctor bled himself 
to the extent of about sixteen ounces ; six hours later he took from the 
arm an additional quantity of about eight ounces. A profuse suppuration 
from the ear soon took place and the pain then became tolerable. For a 
month no marked change occurred in the condition of the ear. The dis- 
charge continued, but at times it would almost stop. On the 23d of August 
he had a rigor, which was followed by a return of all the acute symptoms. 
The pain was referred to the base of the brain, the mastoid process and the 
articulation of the jaw. That night the pain, according to his own words, 
was very severe. Bleeding, to the amount of twelve or fifteen ounces, afforded 
some relief, and the discharge again became abundant. For a week the pain 
remained unbearable. On the 31st of August he had another rigor, followed 
by intense pain, referred to the mastoid process, and thence backward 
toward the occiput and occipito-vertebral articulation ; in fact, the whole 
side of the head was painful. There was tenderness over the mastoid pro- 
cess and the auricle was pushed somewhat out from the head. On the 2d 
of September, Dr. Darby, at that time Professor of Surgery in the Univer- 
sity of Columbia, S. C, and Dr. Eobinson, of Winsboro', were telegraphed 
for, but by the time they arrived the discharge had reappeared, and the 
pain had moderated. The mastoid region, however, was still swollen and 
quite tender on pressure. On the 18th of September, no improvement 
having taken place in his condition, the doctor started for New York in the 



314 DIAGNOSIS AND TREATMENT OF 

hope of obtaining relief there. The sea voyage from Charleston benefited 
him very decidedly. The severe symptoms abated, and for some time after 
reaching this city he enjoyed, at least during the day, comparative com- 
fort ; toward night, however, the old trouble returned with greater or less 
severity. During the few days preceding his visit to me he suffered acutely 
from pain in the ear. 

On examination the meatus was found to be normal ; the membrana 
tympani was perforated anteriorly, the opening measuring about two milli- 
metres in diameter and having sharply cut edges ; the Eustachian tube was 
freely previous, and there was only a trace of pus in the middle ear. Mastoid 
region oedematous and tender on pressure. The tenderness also extends 
back toward the occiput. General condition fair. Pulse a little over ninety. 
No heat of skin. At a consultation with Professor James R. Wood and 
Dr. Herman Knapp, it was deemed best to perforate the mastoid process. 
At the patient's own request the operation was performed without ether. 
The appearance of the bone, after the periosteum had been lifted aside, 
was entirely normal. The drill was applied on a level with the upper wall 
of the meatus, and made to penetrate to a depth of three-fifths of an inch 
without encountering mastoid cells. At this depth, however, a tolerably 
firm pad of connective tissue was felt. The supposition at the time was 
that this mass filled the antrum, but on subsequent inspection I became 
persuaded that, owing to the thickness of the swollen integuments, and the 
recumbent position of the patient, I had erred somewhat in the direction 
which I gave to the drill, pointing it too far backward. The pad of connec- 
tive tissue was undoubtedly the outer wall of the lateral sinus. 

October 13th.— Patient passed a fairly comfortable night. Pain much 
easier than before the operation. Ordered quinine (gr. ij., ti.d.). 

October 14th. — Pain again severe. Consultation with Drs. Robert F. 
Weir (Professor Wood out of town) and Herman Knapp. A second per- 
foration was made, this time nearer to the meatus and on a lower level than 
the first. Mastoid cells small in size and congested ; intervening septa 
thick and hard ; no pus found. Tent inserted ; poultices. 

October 15th.— Slight improvement. Appetite rather poor. Ordered 
tinct. ferri chlor. gtt., x., with each dose of quinine. 

October 16th.— Appetite better. Temperature 97°. Pain diminishing. 
Ordered carbolic acid dressings to wound, from which there is a free dis- 
charge. 

October 17th. — Marked improvement in every respect. Poultices to be 
stopped. 

October 23d. Tenderaess over mastoid process almost gone. 

November 14th. — Feels quite well again. There is no discharge from 
the meatus, and the wound behind the ear has healed except at two points, 
corresponding to the two sinuses which lead to the perforations in the bone. 
Patient proposes to return to South Carolina. 



DISEASES OF THE EAR. 315 

A few weeks later I heard from the doctor that there had been no return 
of the pain, and that his general health was quite good again. 

Case X. — Boy, seventeen years of age, in fair general health (New York 
Eye and Ear Infirmary), November 7, 1874. He has had a discharge 
from the left ear during the past ten years. About two weeks ago the dis- 
charge ceased, and he then began to suffer from pain in the left ear. The 
parts behind the ear soon became tender and swollen, and the pain extended 
throughout the entire left side of the head. On examination to-day, I find 
the external auditory canal filled with inspissated pus. The drum-mem- 
brane is perforated anteriorly. The skin covering the mastoid process is 
red, swollen, and tender on pressure. A deep incision, made in the usual 
situation, is followed by such active arterial hemorrhage, that no further ex- 
ploration of the parts can be made at present. Wound stuffed with lint 
and pressure applied. 

November 9th. — Patient has been entirely free from pain during the 
past two days, and there is now a free discharge from the auditory canal 
and also from the wound. The profte introduced into the wound engages 
itself readily between the periosteum and the bone, and then passes for- 
ward and inward quite a distance without encountering any resistance. 
Below the wound there is still some swelling and inflammation of the skin 
and subjacent tissues on the side of the neck. 

November 11th. — To-day, on exploring the bottom of the wound, I dis- 
covered an opening in the bone at a point a little below the level of the 
upper wall of the meatus. The probe penetrated quite a distance into the 
mastoid process, but no crumbling bone or spiculse were encountered. 
Patient's general condition good. 

November 21st. — No return of pain since last note. External wound 
scabbed over. No redness, swelling, or tenderness of adiacent parts. Free 
discharge from external auditory canal. 

Acute inflammation with caries. — If the products of inflammation remain 
confined in the antrum, the resulting pressure upon the lining mucous mem- 
brane of this cavity may be expected sooner or later to induce a caries of 
some portion of the underlying bone. If a free outlet is established for 
these products before the carious process has involved too large an area 
of bone, the parts may, in course of time, return to a healthy condition ; 
but if the pus is allowed to remain pent up in the antrum, we may confi- 
dently expect one of the following results : an inflammation of the mem- 
branes of the brain, the formation of an abscess in the brain itself, or the 
development of a purulent phlebitis of the lateral sinus with basilar menin- 
gitis. 

Case XI. — Male, thirty-five years of age, and of vigorous constitution. 
October 29, 1877. (Case seen in consultation with Dr. J. Simrock.) About 



316 DIAGNOSIS AND TREATMENT OF 

nine weeks ago he contracted an acute inflammation of the right middle 
ear, from bathing in the ocean. The severe pain lasted for a few days and 
then passed away upon the appearance of a discharge from the ear. Of 
late he has again suffered from pain in the affected ear, and throughout the 
entire right side of the head. The pain at times shoots forward into the 
right eye, or backward toward the occiput. The discharge still continues. 
On examination I find the meatus filled with pus. At its inner end a large 
teat-like fleshy mass projects from above downward into the canal and en- 
tirely conceals the drum-membrane from view. When the patient performs 
Valsalva's experiment, pus can be seen to escape from the tip of this pro- 
jecting mass. There is tenderness on pressure over the posterior aspect 
of the right mastoid process, and the conjunctiva of the right eye is notice- 
ably congested. During the past few nights patient has obtained such 
sleep as he could get, in an easy chair, in a semi-recumbent posture, the 
full recumbent posture aggravating his discomfort. By means of Blake's 
snare quite a large portion of the projecting fleshy mass was removed. 
Four leeches were also applied behind the ear. 

November 1st. — No improvement. Pain continues without abatement 
Free incision of the mastoid integuments ; wound afterward stuffed with 
lint. Poultices. 

November 4th. — Decided relief from pain, discharge not quite so abun- 
dant as before. The external wound is kept open by means of fresh tents 
introduced daily. 

November 5th. — Patient passed a comfortable night. No diminution 
in the amount of the discharge. Temperature, at 4 p.m., 99.2° F. 

November 9th. — Four very comfortable days and nights. Patient has 
had only spasmodic attacks of pain, which came on generally toward night 
and never lasted longer than three or four hours. 

November 12th. — External wound has almost healed. The granulation- 
growth in the meatus is now nearly as large as when I first saw it. Blake's 
snare employed a second time in removing a large part of the mass. The 
"neuralgic" attacks continue. Ordered pot. bromid., gr. xv., t.i.d. 

November 17th. — No material change. Granulation-tissue is again 
growing actively. 

November 24th.— The pain is again on the increase. The discharge 
from the ear continues to be abundant. Enlarged the sinus in the pro- 
jecting mass by means of the knife. 

November 26th. — During the night from the 24th to the 25th, the pain 
in the right side of the head was quite severe. It extended to the right 
eye, and was accompanied by congestion of the scleral conjunctiva. 

November 27th.— Patient passed a fairly comfortable night. The ten- 
derness over the mastoid process is very slight. The growth of granulation- 
tissue in the canal takes place very rapidly. To-day several large pieces 
were removed, and yet the more solid base which remains still conceals the 



DISEASES OF THE EAE. 317 

drum-membrane from view. From its position it undoubtedly involves a 
part of the posterior and upper portion of the membrane. A curved probe 
introduced into the sinus encounters exposed but not roughened bone. 
Discharge thick and abundant, but odorless. Appetite good. 

November 28th. — The pain has become more severe. To-day there is 
tenderness on pressure at several points above and behind the ear. No 
swelling or redness of the skin over the mastoid process ; no tenderness 
on pressure immediately over the process proper. 

November 29th. — No improvement. Consultation with Dr. Robert F. 
Weir and Dr. Daniel A. Dodge (of Brooklyn), both of whom agreed with 
Dr. Simrock and myself with regard to the advisability of perforating the 
mastoid process. The patient having been brought under the influence 
of ether, the mastoid integuments were incised, and the opening in the 
bone was made at the usual spot. The drill was carried to a depth of 
nearly three-fourths of an inch. The cells were found to be of mode- 
rate size and healthy, so far as we could judge. The septa were quite 
thick. At the upper portion of the bottom of the excavation thus made in 
the mastoid process, the probe encountered soft tissue. The sinus in the 
projecting fleshy mass at the bottom of the meatus was explored more 
thoroughly than had been found practicable when the patient was not un- 
der the influence of an anaesthetic, and it was ascertained that the bone 
constituting the lateral and lower edges of the entrance to the antrum was 
denuded and in a roughened condition. No communication could be dem- 
onstrated (by means of two probes) between the middle ear and the bottom 
of the excavation in the mastoid process. External wound dressed with 
salicylic jute. 

November 30th.— Patient says that he passed a comfortable night, and 
experienced less pain than usual. When the probe is pressed against the 
soft tissues at the bottom of the artificial opening in the bone, he says that 
he feels the pressure in the ear. From the direction taken by the drill, 
from the depth to which it was made to penetrate, and from the patient's 
sensations as just described, there can be very little doubt that the soft tis- 
sues at the bottom of the artificial opening represent the swollen mucous 
membrane of the antrum. 

December 1st. — Last evening the patient's temperature rose to 100.4° F. 
and he experienced considerable pain throughout the right side of the head. 

December 3d. — No appreciable improvement since last date. Vaseline 
dressings substituted for the salicylic jute, which seems to irritate the ex- 
ternal wound. 

December 4th. — Evening temperature normal last evening. 

December 10th. — Pain still continues, but is severe only at times, espe- 
cially toward night. Since the 29th of November, when the mastoid pro- 
cess was perforated, there has been no further growth of granulation-tissue 
in the external auditory canal. 



318 DIAGNOSIS AND TREATMENT OF 

December 13th. — Discharge from ear increasing. External wound re- 
duced to very small dimensions. Lateral headache quite severe yesterday. 
This morning the right conjunctiva is again congested. 

December 29th. — Since last date patient has experienced fully as much 
pain as during any previous two weeks. The pain "seems to be directly 
proportionate to the degree of obstruction offered by the mass of granula- 
tion-tissue at the inner end of the external auditory canal ; for when this is 
cut away sufficiently to permit the pus to escape freely from the middle 
ear, the pain abates in a very marked degree. Three or four such attempts 
at excision have been made during the past two weeks, but all of them have 
been very imperfect, owing to the severity of the pain caused by the opera- 
tion. To-day, however, the patient was etherized, and Dr. Simrock and I 
excised the greater part of the obstructing' mass. It was found to involve 
a considerable part of the posterior half of the drum-membrane, and was 
composed of very firm tissue. The task of excising this mass was found to 
be exceedingly difficult. The moment the knife began to cut, the flow of 
blood completely obscured the field of vision, and owing to the proximity 
of important organs (anvil and stirrup) it was thought desirable not to pro- 
ceed without a clear view of the parts which it was proposed to cut. Not- 
withstanding this, it was discovered, at the close of the operation, that the 
anvil had become loosened in its attachments. 

December 30th. — Patient passed a very comfortable night. There is 
now quite a large opening in the drum-membrane, and the surrounding- 
parts are very little swollen. 

December 31st. — No return of pain. 

January 9th. — Since last date, and without any therapeutic interference 
beyond keeping the ear clean with the warm douche, the middle ear and 
drum-membrane have been rapidly returning to a healthy condition. There 
is very little discharge. A small perforation still exists in the posterior 
half of the membrane. Otherwise the membrana tympani presents a nearly 
natural appearance, the outlines of the short process and handle of the 
hammer being distinctly recognizable. The external wound has nearly 
healed. Patient is now able to sleep through the entire night, and says 
that his head feels perfectly natural. The ticking of the watch is heard 
only when it is pressed against the auricle. 

A few days later Dr. Simrock reported that the perforation in the mem- 
brana tympani and the external wound had both healed. 

Case XII— On the 21st of September, 1872, I was asked by Dr. Her- 
man Knapp to see with him, in consultation, a Mr. F., aged fifty-seven, 
and of a strong constitution. The history of the case was briefly this : Dur- 
ing the previous ten or twelve years Mr. F. had had five distinct attacks of 
acute purulent inflammation of the left middle ear, from all of which he 
made a good recovery. The present attack began about seven weeks pre- 



DISEASES OF THE EAR. 319 

viously, and was characterized by headache and dulness of hearing, unac- 
companied by discharge. On examination of the ear Dr. Knapp found the 
external auditory canal swollen, especially on the posterior side ; the mem- 
brana tympani injected, and the mastoid process tender on pressure. In 
the progress of the disease, the membrana tympani becoming more con- 
gested and convex outwardly, the doctor incised it. No pus escaped, but 
the patient experienced relief from his suffering for about a week. The 
pain then returned, and the integuments covering the mastoid process be- 
came swollen. The patient also noticed a gurgling sensation in the ear, 
whenever he shook his head. An incision down to and through the mas- 
toid periosteum afforded only temporary relief. The pain again became 
severe. At the consultation (September 21st) it was decided that perfora- 
tion of the mastoid process was the only course that offered any hope of re- 
covery. The patient, however, refused to have the operation performed. 

September 22d. — Up to this time there had been no brain symptoms, 
but to-day, being called in haste to see the patient during the absence of 
Dr. Knapp from the city, I found him unconscious, pupils non-responsive, 
face flushed, and head very hot ; pulse about 120, and full ; breathing ster- 
torous. The friends were then willing enough to have the operation per- 
formed, but it was clearly too late. The patient died the same night. 

At the post-mortem examination, purulent basilar meningitis was found, 
together with a free communication between the mastoid antrum and the 
cavity of the lateral sinus. The two formed together an irregularly shaped 
cavity filled with pus. The pus did not extend down into the jugular vein, 
nor back toward the torcular Herophili. Both these portions of the vein 
contained venous blood. Sclerosis of the mastoid cells. Membrana tym- 
pani entire. 

Case XTTT. — Male, about forty-five years of age and of strong constitu- 
tion. April 3, 1877 (consultation with Dr. S. Sexton). About six weeks 
ago patient began to suffer from pain in the right ear. The physician whom 
he consulted a few days later, restricted his treatment to the frequent use 
of the syringe and to the administration of internal remedies. The pain, 
nevertheless, grew steadily worse, and involved the entire right side of the 
head. On the 31st of March, Dr. Sexton was asked to treat the case. No 
discharge from the ear had yet been observed by the patient, but on exam- 
ination Dr. Sexton found the meatus inflamed, moderately swollen, and 
covered with a small amount of pus. Two incisions were made through the 
swollen walls of the canal. The patient continued to grow worse, and to- 
day he has been at times delirious and has vomited his food. It is only 
with difficulty that he can be made to answer our questions. He holds his 
head with both hands, as if in suffering. Pupils normal. Pulse 58 ; three 
days ago it was 100. He refers the chief pain to the occipital region. There 
is but little pus in the canal, and so far as it can be seen the membrana 



320 DIAGNOSIS AND TKEATMENT OF 

tympani has a tough, soaked appearance. No evidence of the existence of 
a perforation. Iodide of potassium to be given in ten-grain doses every 
four hours. 

April 5th. — Patient is to-day profoundly comatose. 

April 7th. — Death occurred this morning. (Post-mortem examination 
refused.) 

Case XIV. — Male, nineteen years of age, in good general condition. 
September 24, 1876. Consultation with Dr. F. Simrock. Patient has been 
subject to chronic purulent inflammation of the right middle ear. Four 
years ago Dr. Simrock ascertained the existence of caries of the bony walls 
of the tympanum, and warned the boy's parents of the danger connected 
with that condition. A week ago the patient began to complain of pain in 
the right ear, and it soon became quite severe. Temporary relief was af- 
forded by a free incision carried through the posterior fold of the drum- 
membrane. The boy had two chills yesterday, followed by vomiting, and 
last night the pain again returned with great severity. To-day the boy is 
so drowsy that he can only be roused with great difficulty. At times he is 
also delirious. On examination, the external auditory canal is found to be 
perfectly natural, except in the immediate vicinity of the membrana tym- 
pani, where it is red and moderately swollen. The membrane itself is of a 
pinkish hue, and much disfigured by inflammatory changes (old). A perfora- 
tion can be distinguished only when air is forced out through it by sud- 
denly condensing the air in the naso-pharyngeal space, by means of a Po- 
litzer's bag. No redness, swelling, or tenderness behind or above the ear. 

From the history of the case, from the condition of the middle ear, and 
from the absence of any redness or tenderness behind the ear, it seemed 
unlikely that, at such an advanced stage of the cerebral disease, any relief 
would be afforded by the operation of perforating the mastoid process. 
An effort was made, however, to bring the patient under the influence of 
mercury (inunctions, and calomel by the mouth), but he grew steadily 
worse, and died two or three days later. 

Case XV. — Saloon-keeper, thirty-nine years of age, and of vigorous 
physique. October 22, 1873. While on a fishing excursion last July, 
patient got a thorough wetting and soon afterward began to suffer from pain 
in the left ear. Deafness in. the affected ear and tinnitus were also noticed 
from the beginning. The pain extended from the ear to the entire left 
side of the head, and was particularly severe in the occipital region. At 
the end of four weeks an abscess of large dimensions developed behind the 
ear, and broke of itself. At no time was there any discharge from the ex- 
ternal auditory canal. Since the spontaneous opening of the abscess the 
patient has suffered chiefly from pain referred to the left temple. He has 
also had frequent attacks of dizziness, though this may possibly have had 



DISEASES OF THE EAE. 321 

some connection with a sunstroke which he experienced about three years 
ago. 

From Dr. Buechler, who saw the patient on about the seventh or eighth 
day of the attack, I learn that he found him in convulsions and with a high 
fever. Several leeches were applied near the ear, and the inflammation 
appeared to have been arrested by this depletory measure. At all events 
Dr. Buechler was not sent for again until to-day. 

At the present time the ticking of the watch is not heard at all in the 
left ear, even when it is pressed against the auricle. The sound of the tuning- 
fork, however, is referred very promptly to the affected ear. On examina- 
tion with the speculum and reflected light, the meatus and membrana tym- 
pani were found to be almost free from evidences of inflammation. The 
drum-membrane was dull, milky, and apparently thickened ; peripheral and 
manubrial plexuses moderately injected ; no cicatricial spot or other evi- 
dence that a perforation had ever existed. Behind the ear a fistulous open- 
ing is visible. The probe introduced into this, engages itself in a small 
opening in the upper part of the mastoid process, about at the same level 
with the upper wall of the meatus. 

October 23, 3 p.m. — With the assistance of Drs. Buechler and Charles 
Laight, patient was etherized, and a vertical incision was made through the 
mastoid integuments, exposing to view the orifice of the bony fistula. A 
silver probe of ordinary size could be passed directly inward to a depth of 
only about a third of an inch. No loose fragments were felt. The drill 
(diameter J inch) was then engaged in the opening and made to penetrate 
inward a little upward and forward, to a depth of three-fifths of an inch. 
At first the bone was found to be in a softened condition, but deeper in it 
was almost as hard as ivory. A tent anointed with simple cerate was then 
inserted into the wound. 

8 p.m. — Patient complains of feeling very weak and cold. No special 
pain in the region of the wound or in the head. His wife says that he has 
been more or less delirious since the operation. Ordered beef-tea (ca. 3 iij.) 
every three hours, and 

$ . Quinise sulphatis gr. xxxij. 

Acid, sulph. dil q. s. 

Aquae ad 3 iv. 

M. S. — Two teaspoonfuls every three hours. 

October 24th. — Patient feels much better to-day. Quinine solution to be 
taken three times a day instead of every three hours. No pain in head. 
Wound to be dressed with carbolated oil. 

October 25th. — W T ound granulating healthily. Very little swelling of the 
neighboring parts. The tinnitus, which troubled him before the opera- 
21 L 



322 DIAGNOSIS AND TREATMENT OF * 

tion, has now entirely disappeared. Appetite good. Quinine to be stopped, 

and patient to take in its stead : 

3 • Ferri citratis gr. xvi. 

Tinch. cinch, comp § j. 

Aquse | iij. 

M. S. — A tablespoonful three times a day. 

October 27th. — During the past two or three nights patient has had quite 
severe headache — not so severe, however, as before the operation. During 
the day-time he has been free from pain. Urine examined and found to be 
normal. No history or existing evidence of syphilis. Iodide of potassium 
in five-grain doses to be taken three times daily. 

November 1st. — Wound healing rapidly. Pain still continues to be quite 
severe at night. Doses of iodide of potassium increased to ten grains 
each. Small hard-rubber drainage-tube introduced into the orifice of the 
fistula in the bone, as granulation-tissue is rapidly filling up the external 
wound. 

November 5th. — The hard-rubber canula, though kept in position sim- 
ply by the pressure of a bandage passed lightly over the top of the head and 
under the chin, causes him so much discomfort that he is unwilling to wear 
it any longer. The pain at night is much less severe. 

November 10th. — Patient is now entirely free from pain at night. Or- 
dered iodide of potassium to be discontinued. 

November 17th. — Continued freedom from pain. External wound still 
remains open. From time to time it has been found necessary to resort 
to the use of nitrate of silver (in stick) for the repression of an exuberant 
growth of granulation-tissue. 

December 6th. — Two days ago patient again began to experience pain 
at night throughout the left temporal region. Ordered strychnia sulphat., 
gr. ¥ V> t.i.d. 

January 15, 1874. — Pain of late has again been insignificant or entirely 
absent. Patient, however, complains a good deal of dizziness. On in- 
troducing my probe into the bony sinus I found that it could be passed 
upward and backward a distance of an inch from the opening on the outer 
surface of the bone. The probe felt as if it was surrounded by bone on all 
sides, and, from its position, it must have occupied the diploe lying immedi- 
ately behind the sulcus for the lateral sinus. The fear of doing some dam- 
age prevented me from passing the probe any higher up in the direction in 
which it was going, although up to the point reached no obstacle was 
encountered. At all previous explorations it had not been found possible 
to pass the probe into the bone to any but a very short distance. 

The suggestion of further operative interference brought the patient to 



DISEASES OF THE EAR. 323 

the decision that he would wait and see how he should get along without 
medical aid. 

Case XVI. — Female, twenty-nine years of age, in fair general health 
(New York Eye and Ear Infirmary), February 10, 1875. She states that 
she has been subject to a discharge from the left ear since childhood. About 
six months ago a " tumor" was discovered in the affected ear. Several at- 
tempts were made at different times to remove this "tumor," but it con- 
stantly reappeared. Of late she has experienced a great deal of pain through- 
out the entire left side of the head. The pain has been especially severe at 
night, and at times has been accompanied by what she describes as " brain 
fever." Occasionally she has exjDerienced a sensation as if the left eyeball 
were being pushed out from its socket. 

On examination the meatus was found to be blocked by the presence of 
a mass of granulation-tissue. After removing the greater part of this growth 
with the snare, I discovered, by aid of the probe, that it sprung from the 
posterior wall of the meatus, near the junction of the cartilaginous with the 
osseous portion, and that its point of origin was close to the orifice of a 
sinus that led quite a distance inward and a little upward and backward. 
In its course the probe, which did not seem actually to enter the substance 
of the mastoid process, encountered denuded and crumbling bone. No 
redness or swelling of the skin behind the ear. Moderate tenderness on 
pressure over the lower part of the process and also over that portion of 
the skull which is situated immediately in front of the occipital protuber- 
ance. 

She was advised to become an in-patient of the Infirmary, in order that 
she might receive better care than it would be possible for her to receive at 
her tenement-house home. She readily consented and was assigned to a 
bed in a separate room. 

February 13th. — Pain still continues. Patient having been etherized, 
the mastoid integuments were divided, and the bone perforated with the 
larger drill to a depth of three-fifths of an inch. No pus or softened bone 
encountered. Anteriorly, however, the periosteum was found to have be- 
come separated from the underlying bone, thus allowing the probe to pass 
easily along the surface of the bone into the meatus. 

February 14th. — Marked relief from pain. 

February 16th. — Decided swelling and tenderness in front of and above 
the auricle. Motions of the jaw cause pain in the region of the ear. Tem- 
perature nearly normal. 

February 20th. — Since last note patient has had an attack of syncope, 
lasting about one hour, and requiring the use of stimulants. To-day she 
is in about her usual condition. Her temperature varies from 98.5° to 
99.5° F. The pain in her head is nearly constant. The parts around the 
ear still remain swollen. The polypoid mass in the meatus having grown 



324 DIAGNOSIS AND TREATMENT OF 

to such a size as to obstruct the free escape of pus from the deeper regions, 
I removed the larger part of it to-day with the snare. 

February 24th. — This morning patient had two epileptiform seizures of 
short duration. The swelling in the vicinity of the ear has diminished 
quite noticeably. The pain, however, continues. When asked in what 
part of the head she felt the most pain, she replied at once, in the left eye. 
Her answers to other questions were at times almost unintelligible. She 
would begin her answer and then stop as if trying to think what else she 
should say. Temperature remains at about 99° F. Profuse sweats. Occa- 
sional vomiting. 

February 26th. — She is now very restless, and force has to be used to 
keep her in bed. Her mind wanders constantly, and she no longer pays 
any attention to questions addressed to her. The right eye is drawn out- 
ward and the right upper lid droops. Temperature 101° F. 

She died the same night. The discharge from the ear continued to be 
abundant up to the very last. No post-mortem examination was allowed. 
By means of the probe, however, I ascertained that the inner and posterior 
bony walls of the tympanum were denuded and roughened. The bent 
probe passed upward and backward through what felt like a small opening 
in the tegmen tympani, into the cranial cavity (abscess of the brain ?). 

Case XVH. — Female, twelve years of age, of rather delicate appearance. 
May 29, 1874. When the family physician was called to see the patient, 
ten days previously, he found her suffering with a moderately severe head- 
ache, fever, occasional chills, and general malaise. No complaint was made 
of pain in, or discharge from, the ear. After the lapse of a few days, no 
improvement having taken place in the patient's condition, the physician 
made special inquiry with regard to the condition of the ears, and then for 
the first time learned that there had been a free discharge from the left ear 
since the time when the girl was first taken ill, i.e., about a week before he 
was called to see her. The pain in the head continued to increase in severity, 
the fever became more pronounced, the chills occurred more frequently (as 
many as six in the course of the day), and there was occasional delirium. 
At the time I saw the patient, her condition was as follows : Temperature, 
107° F. ; pulse, 140. She made no response to questions that were ad- 
dressed to her. Low muttering delirium. Eyelids half-closed, and eyes 
rolling about constantly. Pupils dilated (equally), and fully responsive to 
light. No strabismus. Tongue thickly coated. Examination of the left 
ear revealed the following condition : No redness or swelling of the mastoid 
integuments ; external auditory canal normal in its outer portion ; only a 
moderate amount of pus. At the inner end of the meatus a mass of polypoid 
granulations conceals the deeper parts from view. After removing this 
mass with the snare, I found that it grew from the neighborhood of the 
mouth of the antrum, through a perforation in the posterior and upper por- 



DISEASES OF THE EAE. 325 

tion of the drum-membrane. A curved probe introduced into the antrum 
encountered denuded bone. Treatment : four leeches to be applied to the 
mastoid region, and three in front of the ear ; the warm douche to be used 
frequently. 

May 30th. — Temperature, 102. 5° F. Delirium and unconsciousness still 
continue. 

May 31st. — Delirium of a more pronounced character. Constant jacti- 
tation. Pupils dilated and no longer responsive to light. Pulse 168 and 
irregular. 

Death occurred on the following day. 

Case XVHL — Male, twenty-five years of age, in excellent physical con- 
dition. October 1, 1875. Frequent earaches and discharge from both ears 
since childhood. For a period of about two years he has had no discharge 
from the ears until within the past three weeks. He is now so deaf that I 
am obliged to speak to him in a very loud tone. (For the history of the 
left ear, see Case II. on p. 267.) On examination of the right ear, an unu- 
sually hard fleshy mass is found occupying the inner end of the narrowed 
meatus. It fits the meatus so closely that I am unable, by means of the 
probe, to locate its exact origin. Its base, however, is clearly very broad. 
By means of Blake's snare, I succeeded in removing only a small portion 
of the mass. 

October 2d. — Another portion of the mass removed with the snare. 

October 3d. — Two or three more small pieces removed. 

October 4th. — Snare used for the fourth time, and with nearly the same 
results as on previous occasions. The mass proves to be larger than I first 
estimated it to be. 

October 5th. — Two portions removed. 

October 7th. — Snare again used, and with the same results. I then split 
the fleshy mass with a suitable knife, and introduced nitrate of silver, in 
the form of a bead fused upon the end of a cotton-holder, into the centre 
of the growth. 

October 8th. — No unpleasant reaction followed the use of the caustic. 
On the other hand, it does not appear to have exerted the slightest influ- 
ence in causing any considerable portion of the mass to slough away. One 
seizure effected with the snare. 

October 9th. — Mass incised as before, and liquor ferri subsulphatis (on 
a small pledget of cotton wound round the end of the cotton-holder) intro- 
duced into the very centre of it. 

October 10th. — No material change in the condition of the fleshy mass. 
Application of subsulphate of iron repeated. 

October 11th. — To-day, for the first time, there are evidences of inflam- 
matory reaction in the right ear ; the meatus being decidedly swollen. No 
further interference until the inflammation shall have entirely subsided. 



326 DIAGNOSIS AND TKEATMENT OF 

October 13th. — Patient complains of considerable pain throughout the 
right side of the head. The discharge, which heretofore has been rather 
scanty, is now profuse, and is tinged with blood. Slight tenderness of the 
mastoid integuments. 

October 14th. — Patient is again free from pain, and there is no tender- 
ness on pressure over the mastoid process. Two successful seizures made 
with the snare. 

October 15th. — Snare used again with moderate success. Owing to the 
small size of the meatus, and to the unusual toughness of the fleshy mass, 
causing the wire loop to bend upon itself the moment it is pushed a short 
distance beyond the visible end of the growth, the numerous seizures thus 
far made have accomplished comparatively little in diminishing the size of 
the obstructing mass. Enough, however, has now been removed to afford 
a fairly free outlet for the profuse discharge, the greater part of which 
seems to come from the mastoid antrum, 1 through an irregular opening in 
the upper and posterior part of the drum-membrane — the exact condition 
of which cannot be ascertained, owing to the presence of the fleshy mass. 

On the 17th of October the patient returned to his home for the pur- 
pose of taking a rest for a few weeks, as it did not seem wise to make any 
further efforts at that time to remove the remainder of the obstructing 
fleshy growth. The following extracts from a letter written by the patient's 
father, on the 8th of November, furnish a clear history of the subsequent 
course of the disease. 

"We left New York on Sunday evening, the 17th of October, arriving at 
home on Monday afternoon, the 18th. My son bore the journey well, and 
remained free from pain for about two days, with the exception of experien- 
cing a confused sensation in the head. On Thursday, the 21st of October, he 
was seized with a violent pain in the right ear and side of the head. Dr. R 
prescribed leeches, but that not relieving him, a liquid blister was applied 
at the back of the ear with a brush, followed the next day with a fly blister ; 
but nothing seemed to afford him relief, and he obtained but little sleep at 
night. During this time he was not confined to his bed, and on Sunday 
morning, the 24th of October, he took a long walk, hoping to shake off 
the pain. That afternoon he was taken a great deal worse, and had to go 
to his bed ; Dr. R gave him a dose of morphine to induce sleep. Vomit- 
ing and violent retching ensued during the night, and continued for three 
days, during which time nothing would stay on his stomach. Heated cloths 
and linseed poultices were constantly applied to his ear during his illness. 
The doctor was afraid to apply ice to the head for fear of increasing the 

1 From the history of the case, and from the conditions observed in the ear, there 
can be very little doubt about the existence of a limited carious process in the antrum 
or in the upper and posterior portion of the tympanic cavity proper. The sensitiveness 
of the parts prevented me from actually demonstrating its existence by means of the 
probe. 



DISEASES OE THE EAR. 32 f 

trouble in the ear. After the one dose of morphine, no more was given, but 
bromide was substituted, two teaspoonfuls being administered every three 
hours. 

" On Wednesday, the 27th of October, the face became partially paralyzed 
on the right side. 

" On Friday, the 29th of October, his ear began to discharge freely, which 
seemed to give him some relief, and this discharge continued more or less 
to the end. 

" The retching ceased about three days before his death, and we managed 
to give him a little beef-tea and jelly from time to time. He was uncon- 
scious from Saturday afternoon, the 30th of October, but although delirious, 
he was not at all violent. He wandered a good deal, fancying he was sail- 
ing in a yacht or rowing in a boat, an amusement of which he was very 
fond. He remained unconscious to the time of his death, which took place 
on Monday evening, the 1st of November, at 8.30, having been ill twelve 
days. He passed away peacefully and gently, his breathing ceasing as sud- 
denly and as noiselessly as the cessation of the ticking of a clock when run 
down." 

Case XIX. — (New York Eye and Ear Infirmary. ) Michael Casey, twenty- 
three years of age, a sufferer from pulmonary phthisis, applied to me, March 
20, 1872, for relief from a painful affection of his left ear. He stated that 
two months previously he first noticed a discharge from his left ear ; that 
at first there was no pain connected with it, but that when the discharge 
became copious, as it did about two weeks before, he began to suffer from 
earache. On examination the left meatus was found to be completely closed 
by a collapse of the upper cutaneous wall. After the speculum had been 
forced in for a certain distance, it encountered a mass of granulations, which 
obstructed a view of the deeper parts. Three leeches applied near the ori- 
fice of the meatus. 

March 23d. — Better. The motion of the lower jaw produces pain in the 
left ear. Granulations removed with Blake's snare. Probe encountered 
denuded and roughened bone surface in the meatus. 

March 30th. — Paralysis of the left side of face noticed to-day for the first 
time. 

April 6th. — (Edema of the skin above and behind the ear. Incision over 
mastoid process gave escape to a large quantity of pus, a part of which was 
confined between the periosteum and the bone, the surface of which was 
somewhat roughened. Occasional nausea to-day. 

April 8th. — Is steadily losing strength. Pulse, 112, and feeble. Suffers 
great pain throughout the left side of head, but does not refer it to the mas- 
toid region. On my advice the patient entered St. Luke's Hospital, where 
he could obtain proper food and nursing. 

On the 9th of April, Dr. George A. Peters made a free incision through 



328 DIAGNOSIS AND TREATMENT OF 

the upper wall of the meatus, exposing to view the denuded and roughened 
bone, and giving a free outlet to the pus that had accumulated above the 
auricle, and to that which was constantly forming in the deeper parts of 
the ear, but had hitherto found an escape chiefly through the Eustachian 
tube. 

The operation afforded the patient great relief ; but in the course of a 
few days, the temperature rose to 106°, the cerebral symptoms became 
alarming, and the patient died comatose. 

At the post-mortem examination the dura mater covering the convexity 
of the left hemisphere was found to be intensely red ; on the right side it 
was nearly normal. Pus at the base of the brain on the left side. Dura 
mater covering the left tegmen tympani thickened and of a maroon color. 
The thickened portion, whose limits were very abrupt, resembled closely 
an elevated and swollen Peyer's patch. Between the swollen dura mater 
and the greenish, softened tegmen tympani lay quite a collection of cheesy 
disorganized pus. The lateral sinus was not involved. The antrum 
mastoideum was nearly filled with a cheesy mass enveloped in a coating of 
foul greenish pus. The mastoid cells were sclerosed. A small sinus led 
from the outer surface of the upper portion of the process directly inward 
to the antrum. (It was not detected during life.) The tympanum was filled 
with the same greenish, foul pus, which had also accumulated in the vesti- 
bule and scala tympani, owing to the destruction of the stirrup and mem- 
brane of the round window. The lining mucous membrane of the tympa- 
num was not recognizable ; the pus seemed to be lying in direct contact 
with the bone. Membrana tympani totally destroyed. The cavity of the 
temporo-maxillary articulation filled with pus. Eustachian tube ulcerated 
and very much enlarged. The pus had also burrowed down in the direction 
of the basilar process of the occipital bone. 



II. Acute Inflammation of both the Antrum and the Pneumatic Spaces. 

In a second series of cases the inflammation extends beyond the limits 
of the antrum and involves the pneumatic spaces. The inflammation of 
these spaces may stop short at the congestive stage, or it may go on until 
the cells become filled with pus, and sometimes even until a necrosis of the 
bony septa takes place. The diffuse redness, swelling, and tenderness of 
the mastoid integuments furnish good evidence that such an extension of 
the inflammation to the pneumatic spaces has actually taken place. Far- 
ther on I will call attention to the exceptions which must be made to this 
rule. 

The following cases, which are divided into two groups, may be taken 
as fair illustrations of an acute inflammation of the antrum and pneumatic 
spaces. 



DISEASES OE THE EAR. 329 

Cases in which the pneumatic spaces are simply congested. — Case XX. — 
The patient, a female, about forty-five years of age, of rather delicate organ- 
ization, consulted me on the 28th of May, 1874. About three weeks pre- 
viously she had had a severe earache in the right ear. It lasted for two 
or three days, and then passed away simultaneously with the development 
of a discharge from the ear. A few days before she came to see me, how- 
ever, the pain had returned, and had become quite severe. She was un- 
able to sleep. The mastoid integuments were very tender under pressure, 
and somewhat reddened. The external canal was filled with pus. The 
membrana tympani was red, swollen, and disfigured. I made a free inci- 
sion through the posterior half of the drum -membrane, and prescribed the 
frequent use of the warm douche. 

May 29th. — Pain still continues. Five leeches applied to the mastoid 
region. 

May 30th. — The leeches afforded almost immediate relief, and the pa- 
tient experienced a good night's rest. Appetite has returned, and pulse is 
again normal. 

May 31st, 10 a.m. — Patient reports that during the night the mastoid 
region again became painful. She also experienced a sensation of dizziness, 
associated with nausea, and saw dark objects floating before her eyes. She 
vomited two or three times. Toward morning she experienced a peculiar 
sensation of something dropping into the throat from the back part of the 
nasal cavity. On spitting it out she discovered that it was blood. Just be- 
fore the bleeding began, she became suddenly aware that the sense of ful- 
ness and pain had left the ear. The bleeding continued for several hours, 
though growing steadily less until it finally ceased. The quantity thus ex- 
pectorated amounted to about a fluid ounce, and was bright-colored when 
I saw it. Pulse, 100, easily compressible. At 4 p.m. I saw her in consultation 
with Dr. Robert F. Weir. Shortly after my visit the hemorrhage returned, 
and continued until she had again expectorated about an ounce of blood. 
An examination with the laryngeal mirror and reflected light reveals the 
existence of a varicose condition of the veins in the naso-pharyngeal space, 
but no blood at the orifice of the Eustachian tube. Valsalva's experiment 
forces out through the perforation in the drum-membrane only clear pus. 
Treatment : powdered tannin to be blown upon the naso-pharyngeal mu- 
cous membrane. 

June 1st. — Since yesterday patient has had a hemorrhage from the 
lungs ; the quantity of blood raised being about five ounces. No evi- 
dences of lung disease discovered by physical examination. Ear free from 
pain. 

June 2d. — Three or four smaller hemorrhages, apparently from some 
part of the lungs. No fever. Only occasional paroxysms of coughing. 

June 3d. — Hemorrhages continue, but they partake rather of the char- 
acter of bloody sputa. Patient has now a constant short, hacking cough. 



330 DIAGNOSIS AND TREATMENT OF 

Consultation with Dr. James R Learning, who finds apices of both lungs 
congested. Friction with turpentine and alcohol advised. 

June 4th. — Much less cough. No expectoration. 

June 8th. — No cough. She complains only of dizziness and great weak- 
ness. She is to be taken to her home in Troy. (No subsequent data.) 

Case XXI. — Male, forty-two years of age, and very stout. May 21, 
1876. Patient states that ten days ago he contracted a severe " cold in 
the head," which culminated, three days ago, in a sharp earache in the 
right ear, accompanied by subjective roaring sounds and deafness. The 
pain now involves the entire right side of the head, and to-day, for the first 
time, he has noticed the existence of a slight watery discharge from the 
ear. On examination, the cutaneous lining of the inner half of the exter- 
nal auditory canal is found to be red, swollen, and bathed with a colorless 
secretion. The swelling is greatest in the immediate vicinity of the drum- 
membrane — which is almost completely concealed from view — and shades 
off gradually from that point outward. Four leeches to be applied in front 
of the ear ; ear to be syringed frequently with warm water. 

May 2 2d. — Pain abating slowly. 

May 23d. — Almost entirely free from pain to-day. Air enters the mid- 
dle ear readily, when inflation is performed according to Politzer's method, 
but no perforation sound can be heard. The watery discharge, therefore, 
probably comes entirely from the swollen and inflamed walls of the outer 
canal. Nitrate of silver (in the form of a bead) applied lightly to the red 
and ©edematous tissues. 

May 26th. — Patient felt so well yesterday morning that he took a car- 
riage and drove to the lower part of the city — a distance of fully three miles 
— on a business errand. Befo-re reaching home again, the jarring caused 
by riding over the rough pavements had brought back the earache in all 
its former severity. Patient passed a bad night, and is still in suffering to- 
day. Poultices to be tried for the relief of the pain. 

May 27th. — Another bad night. To-day the skin covering the mastoid 
process is red and tender. Free incision through these parts. 

May 28th. — Decided relief from pain. Patient again very comfortable. 

June 6th. — Since last note patient has passed through a moderately 
severe attack of facial erysipelas, the disease beginning at the mastoid 
wound and extending to the forehead, nose, upper portion of the cheek, 
and hairy parts of the scalp just around the ear. The membrana tympani 
and external auditory canal have, in the meantime, returned to nearly a 
healthy condition. 

Case XXII. — Male, twenty-six years of age, in fair general health. 
(New York Eye and Ear Infirmary.) August 25, 1875. History of an 
acute inflammation of the middle ear (L.) of only a few days' duration. 



DISEASES OF THE EAE. 331 



73 



ain severe. Purulent discharge from external auditory canal. On ex- 
amination the membrana tympani was found to be red, swollen, and per- 
forated. Leeches and warm douche were ordered. 

September 4th. — Patient states that the leeches afforded only tempo- 
rary relief. The pain returned with increased severity, and the parts be- 
hind the ear soon became red and swollen. During the past few days he 
has experienced great distress throughout the entire left side of the head. 
Free incision through the tender and swollen mastoid integuments. Poul- 
tices. 

September 18th. — The incision afforded great relief, and patient is now 
comparatively free from pain. The redness, swelling, and tenderness of 
the mastoid integuments still persist, and there is a constant and profuse 
discharge of thick pus from the auditory canal. The external wound has 
healed. 

October 19th. — Patient states that, although at no time entirely free 
from pain, he has experienced no acute suffering during the past month 
until about three days ago. Since then the swelling behind the ear has 
increased quite rapidly, and the pain has become severe again. The auri- 
cle is now pushed forward by a tense red swelling, involving the mastoid 
integuments and extending above the ear and as far forward as the temple. 
A free incision made in the line of the cicatrix of the former cut gave rise 
to such a copious hemorrhage that I was obliged to stuff the wound with 
lint and apply pressure by means of a bandage. 

October 20 th. — I removed the stuffing from the wound to-day and 
pushed an exploring needle from the upper end of the wound forward, 
upward, and inward, in the direction in which — from the degree of swell- 
ing above the auricle — I thought it would be likely to reach pus. In this 
I was successful, and after enlarging the channel of communication I was. 
able, by pressure in front of and above the ear, to drive out about a drachm 
of thick, healthy pus. On probing the cavity from which the pus had 
been forced out, I discovered that the bone in that region was denuded of 
its periosteal covering. There was marked tenderness throughout all this 
region, and decided redness of the infiltrated skin. Poultices ordered. 

October 23d. — External wound has again healed, and the swelling is at 
least as great as on the 20th. Incision repeated, pus evacuated, and a tent 
introduced. The patient promises to insert a fresh one every day. 

October 27th. — No return of pain. Discharge from meatus diminish- 
ing. Probe still encounters denuded bone surface. Daily introduction of 
a tent to be continued for a few days longer. 

November 14th.— Patient is doing well. Tent to be omitted. 

November 24th. — Discharge of pus from external wound has rapidly 
diminished since the introduction of the tent has been omitted. A small 
scab now covers the wound. The discharge from the meatus has ceased. 

December 12th. — External wound has completely healed. No tender- 



332 DIAGNOSIS AND TREATMENT OF 

ness exists at any point in the vicinity of the ear. The drum-membrane is 
intact, and nearly normal in appearance. 

Case XXTTT. — Girl, six years of age, and apparently in robust health. 
October 17, 1874 (New York Eye and Ear Infirmary). During the previ- 
ous March she had passed through an attack of scarlet fever, which had left 
her with a discharge from the right ear. Pain had been a prominent 
symptom of the ear complication during its first stages. About three weeks 
previously the discharge had become profuse, the child had complained of 
pain, and the soft parts just behind the ear had become very much swollen, 
red and tender. A few days later a well-defined swelling had made its 
appearance a short distance behind the mastoid process. At the time 
when I saw the patient, there was still redness, tenderness, and swelling of 
the mastoid integuments. The external auditory canal was swollen and 
filled with pus. About midway between the mastoid process and the occi- 
pital protuberance, and a little above the line connecting these two regions, 
there was a well-defined, fluctuating swelling. A free incision through this 
tumor was instantly followed by such a gush of blood that I was unable to 
determine whether the fluctuation was due to the presence of pus, or to 
that simply of serum or fluid blood. The hemorrhage was arrested by 
stuffing the cavity laid open by the incision, with lint, and then applying a 
compress and bandage. 

October 20th. — She has been comparatively free from pain since last note. 
No further hemorrhage occurred from the wound. To-day, there being- 
evidences of suppuration in the wound, I removed the lint stuffing. 

November 6th. — The child's mother reports that the wound healed soon 
after the last visit, and that the discharge from the ear had diminished very 
perceptibly. She says, however, that during the past few days, the child 
has had cough and night- sweats, and has lost flesh appreciably. On exam- 
ination I find that all manifestations of mastoid inflammation have disap- 
peared, there being now only a subacute purulent inflammation of the mid- 
dle ear, with partial destruction of the membrana tympani. The girl's gen- 
eral appearance, however, has greatly changed. She is pale and emaciated, 
and presents every appearance of a child suffering from pulmonary phthi- 
sis. (No subsequent data.) 

Case XXIV.— Male, twenty-five years of age, in poor general health 
(through constitutional syphilis). New York Eye and Ear Infirmary. No- 
vember 26, 1873. About a week ago patient began to suffer from pain 
in the left ear, followed soon by a watery discharge (tinged with blood) 
from the ear. Both have continued since, and the pain now involves the 
mastoid region. On examination, the auditory canal is found to be filled 
with pus. The membrana tympani is red, swollen, and perforated anteri- 
orly. Mastoid region tender under pressure. Watch heard only when 



DISEASES OF THE EAR. 333 

pressed against the ear. Syphilitic inflammation of the pharynx, with de- 
struction of a portion of the soft palate. Patient is now under active con- 
stitutional treatment (in the throat department of the Institution). The 
perforation in the drum-membrane being very small, a free incision was 
made to-day through the posterior half. Three leeches to be applied to- 
night to the mastoid region. 

November 29th. — No improvement. Instead of three leeches, the pa- 
tient allowed only one to be applied behind the ear. During the past forty- 
eight hours he has had quite an active diarrhoea (sixteen stools). 

December 1st. — Patient has remained in bed since the last note, and 
the diarrhoea has ceased. The pain in the head, however, is rather increas- 
ing, and the skin covering the mastoid process is to-day red and moder- 
ately swollen. Three leeches to be applied to this region. 

December 3d. — The leeches drew well, and the patient experienced de- 
cided relief from pain. This morning, however, the pain returned with in- 
creased severity. A free incision through the mastoid integuments was 
followed by arterial hemorrhage, necessitating the use of the ligature. 
The incision had been carried a little nearer the angle of insertion of the au- 
ricle than is usual in such cases. Poultices to be applied behind the ear. 

December 6th. — Slow but steady diminution in the acuteness of the 
pain. Patient is to take daily four grains of quinine and cod-liver oil, his 
general condition being decidedly poor. 

December 10th. — Two days ago the discharge from the ear ceased. The 
pain comes only in paroxysms now. General condition improving. Ex- 
ternal wound is healing slowly ; at the bottom of it the probe still encoun- 
ters exposed bone. The membrana tympani is red and swollen, but dry. 
No perforation visible. The iodide of potassium, which at first disagreed 
with him, is now taken without the slightest discomfort, in combination 
with the sesquicarbonate of ammonia. 

December 13th. — Continued and very marked improvement. 

December 17th. — As patient is entirely free from pain, he is allowed, 
at his own request, to return home. The external wound has not quite 
healed. 

Case XXV. — Male, twenty- three years of age, in good physical condi- 
tion. May 13, 1876. Four weeks ago, while suffering from a bad " cold 
in the head," he contracted a severe earache in the right ear. Although a 
discharge soon made its appearance, the pain continued for a period of 
nearly two weeks. A period of comparative freedom from pain then fol- 
lowed, but three days ago the pain returned, and the soreness behind the 
ear, which had developed some days previously, became decidedly more 
marked. The pain had not been confined to the ear and its immediate 
vicinity, but involved the entire right side of the head. On examination, 
the external meatus was found to be nearly normal ; the drum-membrane, 



664, DIAGNOSIS AND TKEATMENT OF 

however, was red, swollen, and perforated posteriorly. The skin covering 
the mastoid process was decidedly red and swollen, and very tender when 
pressed upon with the finger. A free incision was made through these 
swollen tissues, the point of the knife being carried along the surface of the 
bone. Subsequent warm, moist applications to the parts. 

May 14th, 8 p. m. — Patient has been entirely free from pain to-day. His 
appetite is returning. 

May 19th. — No return of the pain. The discharge from the meatus has 
ceased, and the perforation in the drum-membrane has healed. There is 
no longer any redness or swelling of the skin covering the mastoid process, 
and the external wound has very nearly healed. Subsequent recovery per- 
fect. 

Case XXVI. — Eichard Murphy, set. 11, phthisical in appearance, con- 
tracted, about the 4th of September, 1872, a pain in the left ear, in conse- 
quence of exposure to cold. Two days later a discharge appeared, and 
from that time to this (September 11th) he has suffered from severe pain in 
the affected ear. To-day the discharge ceased. Patient appears to be in 
great suffering. Pulse 108 and feeble. Tenderness and oedema over the 
left mastoid process. The external meatus closed by the swelling of its 
walls. "Valsalva's experiment caused dizziness and retching. The patient 
being under the influence of ether, an incision was made through the in- 
teguments of the mastoid process. The surface of the bone was found to 
be normal in appearance and consistency. The outer shell of bone was 
then perforated with a conical drill, which exposed to view the mastoid cells 
at a depth of less than two hues. These were found to be highly congested, 
and the thin bony septa readily broke down under the pressure of the steel 
director. No pus was found. A small tent was introduced into the 
wound, and a poultice was applied to the parts. Milk and beef-tea diet." 
Patient to remain in bed. 

September 12th. — Pain has gone, but patient is unable to keep anything 
on his stomach (the effect, probably, of the ether). The discharge from 
the meatus has returned. Some erysipelatous swelling about the wound. 
Ordered lime-water p. r. n. 

September 13th. — Food retained. General condition decidedly better. 
Free discharge from the meatus. Wound granulating. No return of pain. 
Ordered simple dressing to wound, tent to be left out and poultices to be 
omitted ; patient also to take quin. sulph., gr. j., t.i.d., and solid food. 

September 14th. — Erysipelatous blush is fading away. 

September 16fch. — Continued improvement. Patient is now able to 
leave the house. 

September 18th. — A free discharge both from the meatus and from the 
wound. Ordered iron and cinchona to be substituted for the quinine. 

September 21st. — Entire freedom from pain since the operation. His 



DISEASES OF THE EAR. 385 

general condition, however, is not so good as when he last visited me three 
days since. Night-sweats have set in, and his breathing is hurried. 

Since the last note I have not heard from the boy, and have very little 
doubt that he soon afterward died of phthisis. The operation certainly 
gave great relief, but the subsequent copious discharge of purulent matter 
was too great a strain for a system burdened with phthisis, and he probably 
succumbed under both. 

Case XXVII. — (New York Eye and Ear Infirmary). Mrs. Kate Eyan, 
set. 36, with syphilitic destruction of the bones of the nose, but otherwise 
in good health, consulted me January 15, 1873, for a painful affection of the 
right ear. She stated that a week previously she was attacked during the 
night with a severe pain and roaring in the ear. She had always been hard of 
hearing in that ear, but could not recollect ever to have had a discharge from 
it. In the course of twenty-four hours she obtained some relief by the sud- 
den giving way of something in the ear and the appearance of a discharge 
at the outer orifice. Soon, however, the pain returned and gradually be- 
came almost intolerable. It extended over the entire side of the head and 
was accompanied by soreness in front of and behind the ear. On examination 
I found the external auditory canal closed by an oedematous swelling of its 
walls. Membrana tympani perforated, but invisible. Tenderness on pressure 
over mastoid region ; moderate oedema. Tongue coated. Appetite poor. 
Pulse 90 and of fair strength. No appreciable heat of skin. Incision of 
the mastoid integuments. 

January 16th. — No relief from the incision. Pulse 104 and feeble. She 
is evidently in much suffering. Consultation with Dr. Eobert F. Weir. 
Perforation of the mastoid process advised. As the patient preferred to 
bear the pain, the operation was performed without anaesthesia. The bone 
was perforated with the larger of the two drills to a depth of half an inch, 
without encountering pus. The cells were few in number, and separated 
by strong septa. The outer surface of the bone appeared to be perfectly 
normal. Treatment : introduction of a tent into the opening in the bone, 
poultices every four hours, iron and quinine, and moderate stimulation. 

January 17th. — Decidedly better in every respect. Pain moderate. 
Pulse 88. Takes nourishment well. The meatus and the wound to be 
syringed every four hours with a warm, weak solution of carbolic acid. 

January 2 2d. — Continued improvement. Wound granulating. Occa- 
sional shooting pains. 

January 29th. — Entire freedom from pain in the right ear. Wound 
rapidly filling up with healthy granulations. Almost no discharge from the 
meatus. Three days ago, without any apparent cause, the left ear became 
acutely inflamed. Incision of membrana tympani afforded an outlet to the 
pus and relieved the pain. 



336 DIAGNOSIS AND TKEATMENT OF 

February 8th. — Steady improvement. Left ear free from pain. 

February 13th. — No discharge from the right ear since the 10th. A thin 
cicatricial depression indicates the location of the former perforation in the 
membrana tympani. Outer wound entirely healed except at one small spot 
which is still covered by a scab. 

Case XXVIII. — This case commenced as an ordinary acute inflammation 
of the middle ear, resulting in a discharge of pus through a small perfora- 
tion in the left membrana tympani. The patient was twenty-three years of 
age, in fair health at the time, though a frequent sufferer from articular 
rheumatism. His first visit to the Infirmary was on the 19th of March, 1873. 
The acute symptoms had then passed off, and he was simply troubled with 
moderate deafness in the affected ear and a very slight discharge. 

Ten days later, it was found that the opening in the membrane had 
healed over, and that the latter had resumed a comparatively healthy ap- 
pearance. The only thing that attracted any special attention was the ex- 
istence of a faint circular outline in the posterior half of the membrane. 
Siegle's tympanoscope failed to dislodge this supposed bubble fft>m its po- 
sition, and the auscultatory sounds were so thoroughly dry, that I very 
nearly abandoned the idea that there was fluid in the tympanum. To sat- 
isfy myself, however, on this point, I made a linear incision through the 
posterior half of the membrane, and performed suction through Siegle's 
apparatus. No fluid escaped. The linear incision was then converted into 
a crucial one, and suction was again employed. This time a mass of tougb 
mucus was brought through the perforation into the cavity of the meatus. 
This mass remained connected with the mucus within the cavity of the 
tympanum by a round cord of the same substance. By exerting traction 
upon this cord, it could be drawn out to a distance of several inches from 
the ear. The act of suction was repeated two or three times, and each 
time successfully. By having the patient perform Valsalva's experiment 
while I was exhausting the air in the meatus by aid of Siegle's apparatus, I 
found that the mucus could be drawn into the outer canal in larger quan- 
tity and more readily than without the patient's co-operation. The quan- 
tity of mucus thus withdrawn from the tympanum was so great that I could 
not avoid the belief that much of it must have come from the Eustachian 
tube. The hearing, which before the operation was about £■-£, rose to {■-§ for 
the watch. No inflammatory reaction followed, nor did the patient com- 
plain of any special feeling of soreness about the ear. 

On the 2d of April, four days later,— the hearing in the meantime not 
having increased beyond T ^ for the watch, and the perforation having 
healed, — I repeated the operation. The quantity of mucus obtained was 
nearly the same as before, but the hearing remained unchanged. Think- 
ing that very probably the ossicles were enveloped with mucus, I resorted 
to the use of a saturated solution of the bi-carbonate of soda for the pur- 



DISEASES OF THE EAR. 337 

pose of liquefying the mass. The outer canal was filled with the solution, 
and then, while the patient performed the act of swallowing, firm pressure 
was made from without upon the tragus, thus forcing the fluid into the 
tympanum and through the Eustachian tube into the nostrils. At the end 
of a few minutes suction was again performed, and a certain amount of 
fluid was withdrawn from the tympanum, but without any appreciable im- 
provement in the hearing. 

On the 3d of April, the operation was repeated. The soda solution 
was not forced in as before by means of pressure, but was injected through 
the perforation in the membrane by means of a hypodermic syringe, armed 
with a' suitable bent nozzle of gold. This time, after the tympanum had 
been emptied as far as possible of its contents, a warm, weak solution of 
alum was injected into the cavity. The solution was of such a strength 
that the sour taste could barely be recognized by the tongue. It was al- 
lowed to remain about five minutes in the tympanum, and was then with- 
drawn in the manner already described. On this occasion, as on the two 
previous ones, the operation was not accompanied by pain. The fluids 
withdrawn from the tympanum were not tinged with blood, except on the 
first occasion, and then it evidently came from the incision in the mem- 
brana tympani. 

On the 4th of April, I found the patient in very great suffering from his 
ear. The pain, he said, came on early that morning — that is, about twelve 
hours after the injection of the alum — and soon became severe. He re- 
ferred it to the region immediately behind and above the ear. On exami- 
nation, I found that there was moderate tenderness over the mastoid pro- 
cess ; that the membrana tympani was red and abnormally convex, the per- 
foration in it having entirely healed. A vertical incision in the posterior 
half of the membrane gave vent to a large drop of healthy pus, and was fol- 
lowed by some relief from pain. Five leeches were applied behind and in 
front of the ear, and afterward poultices were used. 

From this time till the 13th of April— a little over a week— the pa- 
tient enjoyed comparative freedom from pain. There was a free dis- 
charge of pus, through the perforation in the membrane, and little or no 
fever. The mastoid region, however, continued to remain tender on 
pressure. 

From the 13th to the 16th, the pain steadily increased and was referred 
chiefly to the region behind the ear. The motion of the jaws in eating or 
speaking also became more and more painful. A vertical incision an inch 
long was made behind the ear, down to and through the periosteum, in the 
hope of checking the advance of the trouble in this direction. Poultices 
were also applied. 

On the 17th and 18th, increasing suffering. 

On the 19th of April, his condition was the following : Temperature 
101.5° ; pulse 92, and rather feeble ; motion of iaws verv painful ; meatus 
22 



838 DIAGNOSIS AND TREATMENT OP 

slit-shaped vertically, owing to the swelling of its walls ; the wound behind 
the ear imperfectly healed. 

After consultation with Dr. Robert F. Weir, the patient was etherized 
and an opening was made in the mastoid process, with a one-fourth inch drill, 
to the depth of three-fifths of an inch. The outer surface of the bone was 
normal in appearance ; the mastoid cells were congested, small in size, and 
separated by strong, bony septa ; no pus was found. The opening was 
made on a level with the upper wall of the meatus, and about half an inch 
behind it. The only point of interest connected with the operation was the 
great prostration which followed it. It was only by active stimulation (ac- 
complished with great difficulty) that a fatal syncope was prevented. 

From the 19th to the 22d, the soft parts behind and below the wound 
became more and more swollen and painful. The temperature, which on 
the 20th had fallen to 98.5°, rose slowly to 101°. Warm poultices were 
frequently applied, and iron and quinine were given internally. From this 
date to the 27th, the patient appeared to be making rapid progress toward 
recovery. During the night of the 27th of April, the pain again returned 
with great severity, the temperature rose to 100°, the pulse to 120, and the 
skin near the wound again became very much swollen and tender on pres- 
sure. From the 29th of April the recovery was steady and rapid. 

On the first of June, I found the meatus normal, the membrana tym- 
pani entire, all tenderness gone, and the hearing reduced to about ° T \ for 
the watch. 

Case XXIX. — Female, set. circa thirty, and in excellent health. After 
exposure during house-cleaning on the 1st of May, 1872, she began to suf- 
fer from sore throat, slight deafness, and pain in the right ear. The pain 
soon extended to the parts behind the ear, and gradually increased in se- 
verity, robbing her of her sleep. On the 6th of May I saw her for the first 
time, and found the ear in the following condition : The external auditory 
canal normal ; the membrana tympani red and swollen, though entire ; the 
Eustachian tube closed to Politzer ; very marked tenderness on pressure, 
and some redness of the skin over the mastoid process. Upper portion of 
pharynx moderately congested. Watch heard when pressed against the 
ear. Four leeches applied over the mastoid process gave great relief. 

May 9th.— Pain and tenderness entirely gone. A solution of nitrate of 
silver ( 3 j. — | j. aquae) applied to the still swollen membrana tympani. 

May 13th.— No return of the pain. Swelling of the membrana tym- 
pani diminishing. Watch heard at a distance of half an inch. She subse- 
quently had no return of the pain in that ear, and the improvement in 
hearing was steady and marked. 

On the 8th of the following November I was consulted again for a very 
similar attack in the left ear. The history given was, that about the 1st of 
November she was attacked with a severe pain behind the ear, accompanied 



DISEASES OF THE EAR. 339 

by tenderness on pressure, and a little swelling. The application of six 
leeches to the affected part relieved these symptoms entirely, but on the 
previous night the pain returned with considerable severity. On examin- 
ation I found the left membrana tympani sunken, but not congested. 
Watch heard at a distance of three feet. There was tenderness over the 
mastoid process, and some cedematous swelling of the integuments. Six 
leeches applied behind the left ear afforded entire relief. 

Case XXX.— Infant, seven months old, and apparently healthy. (New 
York Eye and Ear Infirmary.) October 21, 1874. For some time past the 
mother had noticed that there was a discharge from the left ear. Three 
days ago the child began to be very restless, and the mother then discovered 
that there was a swelling behind the left ear. This increased quite rapidly 
in size, and to-day it causes a marked dislocation of the auricle forward. 
The skin covering this tense swelling is red, and fluctuation can easily be 
distinguished on palpation. An incision affords escape to about a drachm 
of thick, healthy pus. By means of the probe introduced into the wound 
it is ascertained that a carious sinus exists in the central portion of the 
rudimentary mastoid process. As the probe passes inward along this sinus 
& crumbling condition of its bony walls can be distinguished. Tent intro- 
duced into the wound. 

October 24th. — The mother reports that since the operation the child 
has been, so far as she could judge, perfectly well. The external wound 
has not yet healed, but there is very little discharge from it, and the sur- 
rounding skin appears to be quite healthy. The discharge from the meatus 
has also diminished in a marked degree. (Child not seen again.) 

Cases in which the pneumatic spaces are filled with pus or the intervening 
septa are in a carious condition. — Case XXXI. — Male, forty-two years of age, 
in good general condition of health. (New York Eye and Ear Infirmary.) 
February 11, 1874. Severe earache (K.) two months ago, followed, in the 
course of about two weeks, by a discharge from the auditory canal. Upon 
the appearance of the discharge, the pain diminished in severity. During 
the past few days he has noticed blood in the discharge. On examination, 
the canal is found to be blocked by the presence of a rather firm mass of 
granulation-tissue. There is an appreciable swelling behind the ear. Firm 
pressure upon it causes about a drachm of sero-pus to escape from the 
orifice of the external auditory canal. The swelling, which is of a doughy 
character, extends some distance below the mastoid process, on the side of 
the neck. By aid of the probe it is ascertained that the mass of granulation- 
tissue springs from the posterior wall of the canal, a little beyond the junc- 
tion of the cartilaginous with the osseous portion of the canal. At the base 
qf the mass the probe enters a sinus which leads upward and backward into 
the bone. At the bottom of it a roughened surface is felt. The removal of 



340 DIAGNOSIS AND TREATMENT OF 

the polypoid mass revealed the existence of an intact drum-membrane. 
Watch heard at a distance of eight inches. 

February 18th. — Granulation- tissue is being slowly reproduced. 

February 21st — Free incision through the mastoid integuments. At 
the bottom of the wound the probe encounters quite an extensive surface 
of exposed bone. 

February 25th. — Wound healing naturally. 

February 28th. — Polypoid granulations in canal removed a second 
time. Two probes passed, the one through the external wound, the other 
through the opening in the meatus, meet. Almost entire freedom from 
pain. 

March 7th. — External wound reduced to very small dimensions. The 
probe no longer encounters exposed bone at the bottom of it. Third re- 
moval of granulations in the meatus ; the remaining raw surface and the 
walls of the sinus freely cauterized with a bead of nitrate of silver fused 
upon the end of a probe. 

March 14th. — Discharge from meatus has ceased. Sinus has apparently 
healed (scabbed over). 

March 18th— Considerable pain in the region of the ear during the past 
two or three days. Discharge has returned, and to-day he is again free 
from pain. On exploration I find that the sinus is now open, and exposed 
bone can be felt at the bottom of it. 

March 25th.— Granulations in the meatus removed for the fourth time. 
Nitrate of silver applied freely. 

April 4th.— No discharge during the past three or four days. Granu- 
lation-tissue, however, still develops at the mouth of the sinus. 

April 8th.— Fifth removal of granulation-tissue. 

May 9th.— Since last note a few small fragments of bone have come 
away with the slight discharge from the meatus and from the external 
wound. No return of granulation-tissue. 

Soon afterward I learned that the external wound had healed and that 
the discharge from the meatus had not reappeared. 

Case XXXK— April 8, 1871, I was called to see Mrs. Peter Green 
(colored), aged forty-seven, and of strong constitution. The story was, that 
on the preceding Christmas she had been attacked with severe pain in the 
right ear, followed soon after by a purulent discharge. Eight days previ- 
ously, the discharge having almost ceased, she had again suffered from a 
severe earache, sleeplessness, occasional vomiting, and at times incoherence 
of speech. At the time of my visit she appeared to be in great suffering. 
Pulse 104 and rather feeble. No heat of skin. Pus escapes through the 
Eustachian tube into the pharynx. Marked tenderness over the mastoid 
process. The external auditory canal closed by the swelling of its walls. 
A free incision over the mastoid process and warm fomentations. 



DISEASES OF THE EAR. 341 

April 9th. — Last night, soon after the operation, the discharge reap- 
peared. 

April 18th. — Comparative freedom from pain since the last note. To- 
day I discovered a mass of granulations springing from the upper and pos- 
terior wall of the meatus, a little beyond the junction of the cartilaginous 
with the osseous portion. 

May 25th. — Occasional attacks of pain. 

June 5th. — Another severe attack of pain last night. Motion of the 
jaws painful. Mastoid process tender on pressure. Ordered two leeches 
to the part. 

June 6th. — Some relief from the leeches. 

June 15th. — Since the last note the pain has been steadily growing 
worse. Leeches have been applied from time to time, but with only tem- 
porary relief. To-day there has been some nausea after meals. 

June 16th. — A sinus discovered leading front the mass of granulations 
mentioned above to the mastoid cells. Consultation with Dr. Robert F. 
Weir. Perforation of the mastoid process advised. The patient being 
under the influence of ether, an incision was made exposing to view the 
surface of the right mastoid process. The lower part of the process ap- 
peared to be softer than natural. The bone was perforated with a small 
drill, and the opening was afterward enlarged by means of a small gouge. 
No pus found. Mastoid cells congested. Two probes introduced into the 
mastoid process, the one through the sinus, the other through the newly 
made opening, were found to meet. 

From this time there was a rapid improvement in all the symptoms. 
Her general health, which had suffered materially by the prolonged sick- 
ness, soon regained its usual standard. On the 27th of July I was unable 
to find any trace of the fistulous opening in the meatus, and the discharge 
had entirely ceased. No return of the pain at any time. 

Case XXXIII. — William McClusky, a resident of Orange, N. J., twenty- 
one years of age, of a healthy constitution, consulted me September 4, 
1872, for a painful affection of the mastoid process. He stated that in June 
he was seized with a severe pain in the ear after bathing. The pain con- 
tinued for three or four days, and then stopped, leaving him quite deaf in 
the affected ear. At the expiration of two weeks a discharge appeared, and 
this had continued since until the fourth or fifth day previous to his visit 
to me. Shortly before the discharge stopped, he noticed some tenderness 
behind the affected ear. The pain, which for four days had been growing 
steadily worse, was referred to the mastoid region, whence it extended up- 
ward and backward to the parietal and occipital regions. Tinnitus. Ap- 
petite poor. Countenance pale. Watch heard at a distance of four inches 
on the affected side. The skin covering the mastoid process red and swol- 
len. External auditory canal diminished in calibre by the falling forward 



342 DIAGNOSIS AND TREATMENT OF 

of the posterior cutaneous wall. Membrana tympani invisible. Incision of 
the integuments covering mastoid process. Free escape of pus and blood. 
The periosteum was dissected up a short distance on either side and the 
underlying bone appeared to be healthy. The following day, September 5th, 
while pressing pretty firmly against the bone with a steel director, it seemed 
to me that the point of the instrument met with less than the usual resistance. 
I then attempted to perforate the outer shell with a small steel drill, and in 
doing so suddenly exposed a large abscess which nearly filled the entire 
mastoid process. The opening was further enlarged with a conical drill un- 
til the little finger could be admitted, and the contents were then entirely 
evacuated. Tent inserted and patient allowed to return to his home where 
he said that he could get further medical treatment. The incision of the 
integuments on the previous day had already greatly alleviated his suffer- 
ings. 

On the 14th of November following he wrote : " The pain never re- 
turned since you performed the operation, and the wound healed inside of 
ten days. I went to a doctor to have it dressed, but he refused to have 
anything to do with it, and said that it was a very dangerous operation, and 
might have killed me ; so I went to a friend of mine and had it dressed. 
In ten days the outside was all healed, and I could hear a great deal better. 
Now I can hear my watch tick about twenty-four inches from my ear." 

Case XXXIV. — Male, twenty- eight years of age, and of robust constitu- 
tion. (New York Eye and Ear Infirmary.) August 25, 1875. About ten 
days ago he began to suffer from pain in the right ear, after bathing in the 
ocean. A discharge soon made its appearance, but the pain has continued 
unabated up to the present time. On examination I find the drum-mem- 
brane red, swollen, and perforated. The skin covering the mastoid process 
is red, swollen, and tender when pressed with the finger. Free incision of 
the mastoid integuments ; warm douche at home. 

September 15th. — The incision afforded almost entire relief from pain. 
The wound, however, has not yet fully healed, and more or less tenderness 
still remains in the vicinity. The discharge from the meatus is abundant. 

October 7th. — During the past few days the discharge has been slight, 
but the pain has returned and is now quite severe. It involves the entire 
right side of the head. There is still tenderness on pressure behind the 
ear, and the skin in this region is red and swollen. Patient having been 
brought under the influence of ether, the mastoid integuments were divided 
in the line of the former incision, and the drill was applied at the usual point 
on the surface of the process, where the periosteum was found to have be- 
come separated from the underlying bone throughout a limited area. 
After two or three turns the instrument suddenly entered an oblong cavity, 
estimated to be about three-fifths of an inch long (vertically) and about a 
quarter of an inch wide. The bone through which the drill passed felt ap- 



DISEASES OF THE EAR. 343 

preciably softer than natural. As the bleeding from the external wound 
was quite active, it was impossible to ascertain whether the cavity referred 
to contained pus, or not. No fragments of bone were discovered. Tent 
introduced into the wound. 

October 8th. — Patient passed a comfortable night. Temperature 99.5° 
F. Carbolized oil dressings. 

October 9th. — Quite sharp pain last night for a few hours. To-day he 
feels again quite free from pain. Introduction of tent to be discontinued. 

October 12th. — Decided increase of pain since yesterday. It is referred 
to the mastoid region. Pulse is to-day quite weak (104), and patient has 
a decidedly drowsy appearance. Temperature 99° F. Three leeches to be 
applied behind the ear ; afterward hot poultices. 

October 18th. — A few days ago a swelling began to develop on the right 
side of the head, midway between the mastoid process and the occipital pro- 
tuberance, but on a little higher level than the line drawn from the latter 
point to the external meatus. This swelling has steadily increased in size 
until now it forms a well-defined lump on the side of the head. On palpa- 
tion distinct fluctuation is felt. The drowsiness noticed on the 12th still 
continues. At the same time the patient's countenance wears an expression 
of suffering. An incision through the centre of the circumscribed swelling 
afforded escape to about half a drachm of thick pus. By means of the 
probe it was ascertained that the pus lay between the periosteum and the 
bone. Pulse ranges from 76 to 84, and is fairly strong. 

October 20th. — Decided improvement in patient's condition. He has 
lost his appearance of drowsiness, and says that the pain is very much less 
than on the 18th. Both external wounds still remain open. The dis- 
charge from the auditory canal has nearly ceased. 

October 27th. — Patient again complains of pain in the right side of the 
head, more particularly toward the occipital region and in the temple. 
The wound made by the last incision has apparently healed, and no visible 
swelling remains, but tenderness on pressure still persists in this region. 
A probe directed backward and upward from the bottom of the mastoid 
wound passes easily onward a distance of an inch and a half without en- 
countering any resistance. Firm pressure over the point reached by the 
end of the probe causes a few drops of pus to escape from the mastoid 
wound. During the past four days, the patient has been able to leave his 
bed and walk about the ward. 

November 20th. — Since last note patient's condition has changed very 
little. His general condition is good. The pain has moderated to such an 
extent that he no longer complains of it. The second wound is again open 
in the form of a very small sinus. Denuded bone can still be felt through 
both openings. 

November 24th. — The two fistulous openings not showing any tendency 
to heal, I to-day connected them by a deep incision, thus converting the 



344 DIAGNOSIS AND TREATMENT OF 

pus-secreting region into an open wound. The bone was found to be de- 
nuded over quite a large area, but at no point could anything like a carious 
process be made out. At one spot an opening in the bone was found. It 
led in an upward direction, and its upper edge was sharp and shelving. 
Whether this opening, which in a normal state probably afforded a passage 
for one of the emissary veins, in the present pathological condition of the 
parts furnished an outlet for the pus that had accumulated between the 
periosteum and the bone, I was unable to determine. Wound to be stuffed 
daily with charpie, for the purpose of favoring its healing from the bottom. 

December 15th. — For several days past the patient has been entirely 
free from pain in the head. The wound is apparently healing perma- 
nently. 

January 15th. — External wound has healed perfectly, and patient feels 
as well as he ever did. 



Temperature Record {Fahrenheit). 

Morning. Evening. 

October 7 . 99° 

8 98.5° 99.5° 

9 98.7° 99.5° 

10 98.7° 99.5° 

11 98.7° 99.5° 

12 99° 99° 

13 99° 99° 

14 98.7° 99° 

15 98.7° 99° 

16 98.7° 99° 

17 98.5° 98.5° 

18 98.5° 98.5° 

19 98.5° 98.5° 

20 98.5° 98.5° 

Case XXXV. — Male, fifty-three years of age, in a poor general condi- 
tion of health. (New York Eye and Ear Infirmary.) March 29, 1876. Four 
days ago he got thoroughly chilled and wet in a rain-storm. The follow- 
ing day he experienced quite severe pain in the right ear, and a slightly 
bloody discharge made its appearance at the orifice of the external auditory 
canal. From that day to the present time the pain has steadily increased, 
and it is no longer confined to the ear, but involves the entire right side of 
the head. Five leeches to be applied behind the ear, where there is ten- 
derness on pressure. Poultices. 

April 7th. — Pain continues with unabated severity. The skin covering 
the mastoid process is red, swollen, and tender. A free incision through 



DISEASES OE THE EAR. 345 

these parts, including the periosteum, was followed by a slight discharge 
of a watery nature. 

April 19th. — Free discharge of pus both from the meatus and from the 
wound. At the bottom of the latter the bone is found to be denuded of 
its periosteum throughout an area equal in size to a nickel five cent piece. 
Feeling confident that the mastoid cells must be in a condition of active in- 
flammation, I applied the drill to the surface of the bone, at the usual spot, 
and, after a few turns of the instruments, reached a distinct cavity of moder- 
ate size, containing thick pus and fragments of the bony septa natural to 
these parts. No anaesthetic was used. 

April 22d. — Decided relief from pain since the operation. 

May 10th. — No return of pain. Two small fragments of bone removed 
from external wound, which has nearly healed. Discharge from meatus 
has ceased. Although free from pain, and not affected with a discharge of 
sufficient amount to act as a drain upon his strength, the patient has the 
appearance of a person far advanced in consumption. The change that has 
taken place in this respect since the latter part of March is very marked. 
The wretchedness of his hygienic surroundings is probably as much the 
cause of this malnutrition as the disease of the mastoid process. 

Patient remained under observation until May, 1877. At that time a 
fistulous opening still existed in the mastoid region. For days he would 
have no active discharge, and then the scab would yield and give exit to a 
few drops of pus. The probe could then still be passed deeply into the 
body of the mastoid process. At times it encountered a sort of bone sand, 
but at the last visits merely denuded bone was encountered. His general 
health had improved, and he had not developed any symptoms of pulmon- 
ary phthisis. The middle ear proper remained free from evidences of 
active disease. 

Case XXXVI. — Female about fifty years of age, and of apparently robust 
health, New York City, January 5, 1874. 

About three weeks ago she began to suffer from pain in the left ear. It 
steadily increased in severity, and a few days ago a discharge showed itself 
in the external auditory canal. Dr. George K. Cutter, who was then called 
to see the case, applied several leeches . in close proximity to the ear. As 
the relief obtained was only partial, he yesterday incised the mastoid in- 
teguments freely. At the present time the pain is referred to the entire 
left side of the head, but it is much less severe than before the incision 
was made. The mastoid integuments are still red, swollen, and tender. 
The external auditory canal is filled with pus. "With the view of increasing 
the counter-irritant effect of the wound in the mastoid integuments, I ad- 
vised free cauterization of its raw surfaces with nitrate of silver. 

January 15th. — For a few days the patient remained comparatively 
free from pain, but it soon returned and is now again quite severe and con- 



346 DIAGNOSIS AND TKEATMENT OF 

stant. While I was exploring the bottom of the external wound with the 
probe, the end of the instrument engaged itself in an opening in the bone, 
and I then pushed it on to a depth of a quarter of an inch. The withdrawal 
of the probe was followed by the appearance of a drop or two of pus at the 
surface of the wound. By means of the larger of the two drills, I estab- 
lished an opening in the mastoid process, fully half an inch in length and 
a quarter of an inch in diameter. No appreciable softening of the bone 
was recognized. Upon withdrawing the drill an unusually copious flow 
of blood followed. The hemorrhage was allowed to continue for a short 
time, but as it showed no tendency to grow less active, styptic cotton and 
pressure were resorted to for the purpose of arresting the flow. 

From this time forward the patient improved quite rapidly, and was 
soon considered well enough to resume her daily duties and dispense with 
medical aid. 

March 4th. — For a period of nearly five weeks following the operation, 
patient remained free from pain. During the past ten days, however, she 
has again been in suffering. The pain has been steadily increasing and is 
now quite severe ; it is referred to the region above and behind the ear, 
and even as far back as the occipital protuberance. On examination of the 
meatus it is found that a mass, consisting partly of prolapsed upper cuta- 
neous wall and partly of granulation-tissue, blocks up the inner end of the 
canal. A probe introduced into the sinus behind the ear encounters at the 
bottom of it denuded bone surface over a limited extent. I removed the 
granulation-tissue in the meatus by means of Blake's snare, and ordered 
five leeches to be applied around the ear. Patient to remain in bed. 

March 5th. — Decided relief. The prolapsed wall of the meatus has re- 
turned nearly to its normal position. The discharge is abundant. 

March 9th. — Since yesterday the discharge has markedly diminished in 
quantity, and the pain has again returned. It is now referred by the pa- 
tient almost entirely to the left temple, which is very tender on pressure 
over an area of about the size of a silver dollar. The pain is often of a 
shooting character. The muscles about the left eye are to-day in a constant 
state of contraction. Three leeches to be applied to the region of great- 
est tenderness. 

March 10th. — Very little, if any, relief from the leeches. Discharge 
from the ear still very scanty. She says that the pains occasionally shoot 
through from the side to the back of the head. Temperature, 100° F., 
pulse, 82. Blister to be applied to the left temple. She is also to begin 
taking iodide of potassium, five grains three times a day, and two pills of 
aloes and iron every night (for her habitual constipation). 

March 11th. — -The discharge from the ear is again quite abundant, and 
patient suffers less from pain. To-day there is marked oedema of the left 
zygoma and eyelids. Temperature, 102° F., pulse, 80. 

March 12th. — Last night patient suffered intensely from pain in the 



DISEASES OF THE EAR. 347 

left frontal region. A hypodermic injection of Magendie's solution of the 
sulphate of morphia (TTLviij.) afforded relief for several hours. At the 
time of my visit (3 p.m.), however, she was again in great suffering. Dis- 
charge continues to be abundant. Temperature, 102° F. In the belief 
that the continuation of the pain and inflammation might be due to the 
blocking-up of the matter at its only point of exit, viz., the small and slit- 
shaped opening in the membrana tympani, I made a free incision through 
the posterior half of the drum-membrane and extended it upward through 
the posterior fold. The hemorrhage was very slight, and no noticeable 
escape of pus followed the incision. Nevertheless, in the course of a few 
minutes, the patient expressed herself as having very decidedly less pain. 
Her expression of countenance also indicated this relief in a marked 
manner. I ordered Politzer's inflation to be carried out two or three times 
in the course of the day, for the purpose of preventing the edges of the in- 
cision from healing too soon. 

March 13th. — Patient feels very comfortable to-day. Temperature, 
100.6° F. in the morning, 99.5° F. in the evening. 

March 14th. — She continues to remain free from pain. Appetite very 
poor. (Edema of eyelids and vicinity disappearing. Temperature, 99° F. 
in the morning, 100.2° F. in the evening. Iodide of potassium to be dis- 
continued. 

March 16th.— Temperature, 99.5° F. 

March 17th.— Temperature, 98.5° F. 

March 25th. — During the past week she has been entirely free from 
pain and there has been no discharge from the ear. The sinus behind the 
ear has also healed perfectly. 

Case XXXVII. — Female, thirty-five years of age, in fair general health, 
March 17, 1876. A little over three weeks ago a severe earache developed 
in the left ear. In the course of a few days a purulent discharge from the 
external auditory canal made its appearance, and the pain then became 
more tolerable. For a period of a few days she remained entirely free from 
pain, but four days ago it returned with increased violence, and has con- 
tinued, with very little if any abatement, up to the present time. The 
discharge is now profuse, and the pain involves the entire left side of the 
head. There is decided tenderness over the mastoid process, but there is 
no appreciable redness or swelling. Examination with the speculum and 
reflected light reveals a prolapsed condition of the upper cutaneous wall of 
the meatus. Pressure with the cotton-holder causes pain. The drum- 
membrane is invisible. Mastoid integuments freely incised. Ordered liq. 
opii. comp., gtt. xv. every hour (beginning at 8 p.m.), until sleep is pro- 
cured. 

March 18th. — Incision afforded decided relief from pain. She feels 
comparatively comfortable this morning. 



348 DIAGNOSIS AND TREATMENT OF 

March 20th. — No return of pain. Appetite is fair. More or less oedema 
of the skin in the vicinity of the external wound. 

March 24th. — Patient remains in a very weak condition. Pulse 125 
and feeble. Temperature normal. She has had no chills or chilly sensa- 
tions, no sweats, no nausea. At times she complains of pain in the head, 
but says that it is not severe. The external wound still remains unhealed 
at one point, and the probe introduced into it encounters, at the bottom of 
the sinus, denuded bone. In the vicinity there is still decided tenderness. 
After consultation with my father, Dr. Gurdon Buck, the patient was ether- 
ized, the wound was enlarged, and the larger drill was applied to the 
denuded bone surface. The bone was found to be quite soft, and a cavity 
(one of the larger cells ?) was reached after two or three revolutions of the 
drill. Owing to the amount of blood present in the wound, it was impos- 
sible to determine whether this cavity contained pus or not. No loose 
fragments of bone were felt with the probe. 

March 25th. — She passed a rather uncomfortable night, on account of 
pain. This morning, however, she is free from pain, and in good spirits. 

March 26th. — A little fever toward night. 

March 27th. — Ordered quin. sulph., gr. iv., to be taken at 3 p.m., also a 
milk punch at night. 

March 28th. — No return of fever last night. General condition im- 
proved. Quinine and milk punches to be continued. 

April 12th. — Improvement has been going on steadily but very slowly. 
The wound behind the ear has nearly healed, and there is scarcely any dis- 
charge from the ear. Yesterday she began to complain of pain in the left 
shoulder and clavicular region, and in the muscles of the left side of the 
neck. Slight tenderness, but no redness or swelling of these parts. Tem- 
perature a little above the normal. 

May 11th.— Since last note, patient has passed through a severe siege 
of acute polyarthritis, which has left her in a condition of extreme weakness. 
The discharge from the wound, which had nearly ceased, has again become 
active, and undoubtedly contributes largely to her feeble state. She has 
had no return of acute pain in the ear and head, but at times has a dull 
headache which is confined to the left side. She leaves to-day for the 
country, on a visit to her relatives. (About a year later I learned that she 
had recovered her health perfectly.) 

Case XXXVDX— Strong, healthy woman, twenty-six years of age. 
While nursing a young infant, she was suddenly attacked with a pain in 
the left ear, which lasted about twenty-four hours and then passed off. A 
week later, the pain returned with still greater severity, and lasted three 
days before it began to diminish somewhat in intensity. With the abate- 
ment of the pain she noticed the appearance of a slight yellow discharge at 
the outer orifice. Five days later (February 12, 1873), she visited the In- 



DISEASES OF THE EAE. 349 

firmary. The inner half of the meatus and the membrana tympani were 
found to be very much swollen, and accordingly they were incised. 

For ten days subsequently she enjoyed almost entire relief from pain. 
On the 23d, however, she again began to suffer from her ear, the pain this 
time being referred chiefly to the region of the mastoid process. In the 
course of two days the pain became severe and extended over the entire 
left side of the head. Despite this she continued to nurse her infant, and 
did not visit the Infirmary till March the first. By that time there were 
evident symptoms of commencing mastoid trouble ; namely, redness of the 
skin, oedema, and tenderness on pressure. No appreciable change had 
taken place in the condition of the meatus or membrana tympani. She was 
advised to have the bone perforated behind the ear, but she refused to sub- 
mit to the operation. A free incision, however, was made over the mastoid 
process, and the patient was ordered to apply poultices to the part so long- 
as any pain remained. 

The patient's next visit to the Infirmary was on the twelfth day of 
March. Her story was, that the incision had afforded her relief from the 
pain for a day or two, but that the ear soon became as painful as before. 
Her countenance also indicated prolonged suffering. The wound had en- 
tirely healed, but the mastoid integuments were red, swollen, and very ten- 
der to the touch. 

Her consent having been obtained, the patient was etherized and the 
mastoid process was perforated, as in the preceding case. The outer surface 
of the bone appeared to be perfectly healthy. Instead of applying the drill 
at the spot usually selected, it was made to enter the mastoid process not 
far from its projecting tip. The cell-structure was thus reached at a very 
slight depth and the drill was easily made to penetrate a distance of about 
a third of an inch. It was hoped that this more distant opening would suf- 
fice to relieve the trouble. 

The day following I found her condition improved. The relief from 
pain was very decided. 

March 14th. — Erysipelas on left side of face. 

March 15th. — Entire face involved. Temperature, 105°. Pulse, 108. 
"Wound healthy in appearance. Little or no pain about the ear. 

On the 17th of March I found her again suffering acutely from pain 
in the mastoid region. A careful exploration of the wound with the probe 
led to the discovery of a small sinus in the upper portion of the pro- 
cess, at or close to the spot where the perforation is usually made. The 
probe could be passed into the bone to a depth of three-fourths of an inch 
without meeting any obstacle ; it could also be rotated in a vertical plane 
as if in a cavity of considerable size. The drill was placed over the outer 
orifice of the sinus, and with one or two turns made to penetrate into a 
distinct cavity. On withdrawing the instrument, a moderate amount of 
venous blood escaped, together with a little pus. The bony walls of the 



350 DIAGNOSIS AND TREATMENT OF 

cavity were in a softened condition. The venous hemorrhage soon ceased 
of itself. 

The next day, March 18th, I again found the patient comparatively free 
from pain. The erysipelas was evidently subsiding (temperature 101°), 
and she appeared every way better. The soft parts near the wound, espe- 
cially behind it, were still very much swollen. From this time forward the 
improvement was steady and rapid. 

On the 29th of March she left the Infirmary. There had been no dis- 
charge from the meatus since the operation, and for more than a week she 
had been entirely free from pain. The wound still remained open, but it 
was very much reduced in size and in a perfectly healthy condition. I have 
not since had an opportunity of seeing the case, as the patient did not sub- 
sequently return to the Infirmary. 

Case XXXIX. — Male, silkweaver by occupation, thirty years of age, 
and of rather poor physique. February 7, 1874. Fifteen months ago pa- 
tient was attacked with a severe pain in the right ear. The inflammation 
soon spread to the mastoid cells, an abscess formed behind the ear, and at 
the end of the eighth week it broke spontaneously, affording him relief from 
his prolonged suffering. The fistulous opening which remained after the 
abscess broke, did not heal until six months later. A purulent discharge 
from the ear has been present from almost the beginning of the attack, and 
is now occasionally tinged with blood. Two days ago the pain returned. It 
is confined chiefly to the mastoid region. On examination, the external 
auditory canal is found to be narrowed (slit-shaped almost vertically) to 
such an extent that the deeper parts cannot be seen. The discharge con- 
sists of pus tinged with blood. No tenderness on pressure over the mas- 
toid process or in front of the tragus. Three leeches to be applied to the 
mastoid region. 

May 23d. — The pain was relieved by the leeches, and patient went to 
the country for a few weeks. Two days ago the pain returned, and the dis- 
charge from the ear became more abundant. The pain is referred to the 
right temple. "Warm douche to be used freely. 

May 27th. — Pain continues. Blister to be applied in front of the ear. 

June 3d. — Entirely free from pain. 

July 9th. — During the past three weeks he has again suffered a great 
deal from pain involving the entire right side of the head. Diarrhoea has set 
in, and a fistulous opening has again established itself behind the ear. The 
discharge of pus from this opening is quite abundant, and there is no swell- 
ing or tenderness in the vicinity. A large polypoid growth fills the exter- 
nal auditory canal. After removing this mass with the snare, I discovered, 
by aid of the probe, that the inner and posterior portion of the meatus 
(vicinity of antrum) was in a carious condition. The probe, introduced 
into the sinus behind the ear, encountered denuded bone, and engaged it- 



DISEASES OF THE EAR. 351 

self in a small opening in the mastoid process which led into a cavity con- 
taining loose fragments. The patient having been etherized, I made a free 
incision through the skin covering the mastoid process, enlarged the open- 
ing in the bone by means of the larger drill, made a new opening a short 
distance above the old one, and then broke down the intervening bridge 
of bone. A large and sharply denned cavity, filled with fluid and cheesy 
pus and several fragments of bone, was found in the unusually large mas- 
toid process. The highest point of the cavity was fully three-fourths of an 
inch above the level of the upper wall of the meatus. It was estimated that 
the cavity contained at least a drachm of pus. The largest fragment of 
loose bone removed measured two-thirds of an inch in length, and consisted 
evidently of the peculiar honey-combed structure of the mastoid cells. 

July 10th. — Complete freedom from pain. Appetite good. 

July 11th. — Moderate swelling of the parts surrounding the wound. 
Patient doing well in every respect. 

July 2 2d. — Since the last note patient has complained very much of pain 
in the lower jaw on the right side. There is no redness or swelling in this 
region, but the jaw on this side is everywhere tender to the touch. On explor- 
ing the meatus I discovered that it was nearly closed by a collection of pus 
lying between the upper and posterior bony wall and the skin of the canal. 
Near the stump of the polypus (removed July 9th) I discovered a small open- 
ing in the skin which was apparently the only outlet for this collection of pus. 
Upon enlarging this opening I was able to press out nearly half a drachm 
of pus, and one small fragment of exfoliated bone ; other small fragments 
could be felt with the probe, but no attempt was made to remove them. 

July 2oth. — Great improvement since last note. Patient eats and sleeps 
well and is entirely free from pain. On wiping out the orifice of the ear he 
occasionally finds a small fragment of bone. 

September 20th. — I have not seen the patient since the last note, but 
find him to-day in a very low state. He has no pain in or about the ear, 
but complains ofa" headache " which comes on every afternoon. His gen- 
eral appearance is that of a man in the last stage of consumption. The 
probe can now be passed, through, the opening in the posterior and upper 
wall of the external auditory canal, upward and backward a distance of 
fully two inches from the outer orifice, without encountering any resist- 
ance. The presence of smaller and larger fragments of bone can be readily 
distinguished as the probe is pushed along the fistulous track. Sinus in 
the mastoid region (behind the auricle) still open. 

I did not see the patient subsequently, but am safe in saying that he 
must have died very soon after I saw him. 

Case XL. — (New York Eye and Ear Infirmary.) Mrs. Sarah Curry, set. 
62, of a rather feeble constitution, consulted me July 10, 1872, for a painful 
affection of the left ear. Her story was that for many years she had been 



352 DIAGNOSIS AND TREATMENT OF 

somewhat hard of hearing, especially in the left ear, but had never had any 
discharge from either ear. Two years previously she had an attack of fa- 
cial paralysis, affecting the left side. After a certain length of time this 
passed off entirely. About nine weeks previously she began to suffer from 
pain in and behind the left ear and extending over the entire left side of 
the head. There was also tenderness behind the ear. For two days and 
nights the pain was severe. After that there remained a steady, dull ach- 
ing, together with a moderate degree of tenderness behind the ear. Two 
weeks previously the acute pain again returned, and since then she had 
suffered almost constantly up to the time of her visit to the Infirmary. 

On examination the meatus was found nearly closed by a falling for- 
ward of the posterior cutaneous wall. Membrana tympani invisible. No 
appreciable tenderness in the meatus. No discharge. Tenderness over the 
mastoid process, and also over the lower part of the parietal bone. Watch 
heard when pressed against the ear. The patient's countenance was indica- 
tive of great suffering. Incision of the integuments and periosteum cover- 
ing the mastoid process. No pus found. 

July 13th. — Little or no relief afforded by the incision. To-day the auri- 
cle is pushed forward by a swelling behind the ear. Incision entirely healed. 
A second incision gave exit to about half an ounce of pus. No roughened 
bone or sinus discovered. 

July 18th. — Comparative relief from pain until last night, when the pain 
again became severe. She refers it to the mastoid process, the top and 
back of the head. The meatus is less swollen and the membrana tympani 
can now be seen. It is entire, but of a very tough, opaque, tendinous ap- 
pearance. Eustachian tube open. The entrance of air is accompanied by 
rales. No brain symptoms. Consultation with Dr. Kobert F. Weir. Mas- 
toid process perforated with a conical drill. The outer surface of the bone 
found to be in every respect perfectly sound. At a depth of about one- 
fifth of an inch pus was found filling a cavity about the size of a filbert. 
Pus removed with pledgets of cotton, and outer orifice of the cavity en- 
larged sufficiently to admit the end of my little finger. 

July 19th. — Patient much relieved by the operation, but she still com- 
plains of soreness over the back and side of the head. Pressure over the 
left occipital and parietal regions produces pain. 

July 20th. — Severe pain in the head, behind the mastoid process. Ap- 
petite only moderately good. Is losing strength. Stimulus ordered. 
Wound discharging freely. 

July 22d. — Still severe pain behind the mastoid process. Consultation 
with my father, Dr. Gurdon Buck. Skull trephined about three-fourths 
of an inch behind the mastoid process, at the point of greatest tenderness. 
The outer surface of the bone appeared to be perfectly healthy ; but on 
withdrawing the trephine, after sawing through the outer table, the circu- 
lar track was found to be filled with healthy pus, which had welled up from 



DISEASES OF THE EAR. 353 

the intervening cancellous diploe. No appreciable softening of the bone. 
The removal of the inner button of bone exposed to Tiew a tense, deep-red 
dura mater, but no pus. The subsequent oozing of venous blood from the 
ruptured branchlets was readily checked by laying a pledget of cotton-bat- 
ting in the circular opening. 

July 23d, 11 a.m. — Patient slept a part of the night. This morning she 
has considerable heat of skin. Pulse 100 and feeble. Less pain in the head. 
Eight p.m., pulse 106 and feeble. Intellect perfectly clear. The discharge 
from the mastoid process appears to have nearly ceasecfc. Vomited once 
this evening. 

July 24th, noon. — Patient is evidently sinking. Pulse 110 and very 
feeble. Respirations 44. No rales over anterior and lateral portions of 
the chest. Intellect still clear, but she has not sufficient strength to speak 
in an audible tone when answering my questions. She died on the 26th, 
apparently from exhaustion. 

Post-mortem examination refused by the friends. 

Case XLI. — Boy, eight years of age, and in apparently vigorous health. 
(New York Eye and Ear Infirmary.) October 11, 1876. Since childhood 
he has had an open sore behind the right ear, associated with a purulent 
discharge from the external auditory canal. From time to time he has had 
attacks of pain involving the region of the ear and also the entire right 
side of the head. These attacks have been due, the parents think, to 
" gatherings " behind the ear ; for as soon as a discharge took place from 
the open sore, which was generally scabbed over, the boy experienced re- 
lief from his pain. On examination I find the mastoid region occupied by 
a thick scab, covering the entrance to an excavation in the bone. A probe 
introduced into this cavity, after the scab had been removed, passes direct- 
ly inward, without encountering the slightest resistance, to a depth of 
an inch and a half ; when directed more backward, it encounters resistance 
at a depth of about an inch ; and when directed downward, it passes un- 
obstructed down to the very tip of the process. At no point does the 
probe encounter denuded bone surface. The entire cavity, however, is 
filled with thick and exceedingly foul pus, showing that in all probability 
an active carious process is still going on at some points. No examination 
was made of the meatus and middle ear, and patient never returned for 
treatment, which was to have consisted in a very careful daily cleansing of 
the cavity with warm carbolated (very weak) water. 

Case XLII. — Male, thirty-se^en years of age, in poor general condition 
(pulmonary phthisis). (New York Eye and Ear Infirmary.) January 5, 
1876. He can give no satisfactory account of the commencement of his 
ear disease. He is positive, however, that the discharge from the left ear- 
dates onlv eight months back. About ten days ago he began to suffer from 
23 



354 DIAGNOSIS AND TREATMENT OF 

pain in the affected ear. It rapidly increased in severity, and involved the 
entire left side of the head. On examination I find the meatus filled with 
pus. The membrana tympani is destroyed, and the anvil lies free on the 
bottom of .the tympanum. The upper cutaneous wall of the meatus droops. 
No denuded bone surface can be found with the probe. There is tender- 
ness on pressure over the upper portion of the mastoid process. There is 
also slight paresis of the muscles of the left side of the face. Three leeches 
to be applied behind the ear ; patient to remain in bed. 

January 12th. — Well-marked facial paralysis of the left side. Com- 
paratively free from pain during the past four days. (No further data.) 

Case XLUL — Female, twenty-five years of age, and apparently far 
advanced in phthisis. August 20, 1873. About one year ago she had an 
attack of acute inflammation of the left middle ear. The pain was severe 
for about a day. A discharge then made its appearance, and the pain 
rapidly diminished in severity. Simultaneously with this attack the pa- 
tient began to cough, to lose flesh, and occasionally to raise small quanti- 
ties of blood. The discharge from the ear had continued uninterruptedly, 
and she had experienced frequent attacks of pain, which involved the left 
side of the head, and especially the left temple. On examination a mass 
of granulation-tissue was found occupying the outer portion of the mea- 
tus. It was removed with the snare, and was found to spring from the 
upper and posterior portion of the canal, close to the junction of the car- 
tilaginous with the osseous portion. Its point of origin corresponded with 
the entrance to a sinus that led upward and backward into the mastoid 
cells. The probe encountered loose fragments of bone in its course. 
Deeper parts of ear concealed from view. There was tenderness on pres- 
sure over the mastoid process, and the skin at this point had a purplish 
appearance. 

The unlikelihood of obtaining any material benefit from an operation, 
if made under such conditions, seemed to me to justify a course of non- 
interference. (The patient was not seen again.) 

Case XLIV. — Mr. I. H. N., set. 40, a sufferer from pulmonary tuberculosis, 
was sent to me in consultation by Dr. William Hyde, of Stonington, Conn. 
July 12, 1872. He stated that he became somewhat deaf in the left ear 
eight years previously. In the autumn of 1871 he was attacked with pain, 
roaring and throbbing in the left ear, followed in the course of a week by 
a discharge. Since then the discharge had never ceased, and there had 
always been more or less pain. On one occasion he found a small fragment 
of bone in the discharge. Pain quite severe recently, but not referred 
specially to the mastoid process. 

The condition of the patient at the time I saw him was that of a person 
advanced in phthisis. An examination of the ear revealed a marked degree 



DISEASES OF THE EAE. 355 

of deafness, tenderness over the mastoid process, and pus escaping from 
the meatus, which was quite blocked up by the presence of a mass of gran- 
ulations, springing from the upper and posterior cutaneous wall. During 
the exploration I extracted four loose fragments of bone, which were evi- 
dently bony septa from the mastoid cells. By aid of a curved probe I as- 
certained that a sinus led from the meatus (quite near the outer end of the 
osseous portion) backward into the very centre of the mastoid process. 
In its course the probe encountered two or three sharp projecting spicule 
of bone. The patient was so feeble that I was obliged to desist from further 
exploration. 

On the 28th of September the patient died, with no other symptoms 
than those of exhaustion. Two days before death, there was a considerable 
hemorrhage from the ear. 

No post-mortem examination was made. 



HI. Inflammation of the External Periosteum of the Mastoid Process. 

Some writers describe a primary periostitis of the mastoid process. 
While I do not wish to deny the existence of such an affection, I must con- 
fess that I have never yet seen a case to which I should feel justified in giv- 
ing the title of a primary idiopathic mastoid periostitis. Even the trauma- 
tic form, I think, must be quite rare, as I can find but one instance of the 
kind in my records. The history of this case is as follows : 

Case XLV. — The patient, a strong laboring man, twenty-six years of 
age, sought relief at the Infirmary, on the 15th of October, 1873, for a large, 
tense, fluctuating swelling which occupied the region just above and behind 
the right ear. He stated that four months previously he had received a 
blow on the right side of the head. The injured spot had never ceased to 
be tender and painful since, and recently a swelling had made its appear- 
ance in this region. He had not observed any loss of hearing in the right 
ear, and on testing it with the watch I found that he could hear the ticking 
at a distance of six inches. A free incision at the most dependent portion 
of the tumor afforded escape to about two ounces of thick creamy pus. 
After the pus had been evacuated, a tent was introduced into the wound, 
and the patient was told to introduce fresh tents from time to time. (My 
notes, unfortunately, do not state whether exposed bone was found or not.) 

November 1st. — Patient has allowed the external wound to heal, and 
there is now a second collection of pus, almost as large as that first evacu- 
ated. Incision repeated. 

The patient was very faithful after this in introducing a fresh tent daily, 
and in the course of about two weeks the wound healed permanently. 



356 DIAGNOSIS AND TREATMENT OF 

On two or three occasions I have seen infants or very young children 
with large, tense swellings behind their ears, which seemed to have developed 
independently of any discoverable disease of the external auditory canal or 
middle ear. In these cases, which I had an opportunity of examining only 
after the swelling had attained a considerable size, I assumed that the pri- 
mary disease was an acute purulent inflammation of the middle ear ; and 
that the pus had found an easier way of escape through the opening for the 
central mastoid emissary vein than through the drum-membrane (which, 
probably in these particulax^ cases, was unusually resistant). The antrum 
lies so near the surface in young children, and the intervening bone is so 
soft in comparison with that of the adult mastoid process, that it is quite 
easy to understand how this unusual route might, in certain cases, be the 
easier one of the two for the pus to follow. I give, below, the history of one 
of these cases. 

Case XL VI. — Child, twelve months old, well-nourished, but pale. April 
14, 1879. About four weeks ago the child became very fretful and feverish, 
and seemed to be in suffering. It was not, however, until several days 
later that the parents discovered that there was a small swelling behind 
the ear. This has gone on slowly increasing up to the present time ; all 
sorts of remedies having been tried, in the interval, to dissipate the swelling. 
On examination the auricle is found to be pushed markedly forward by a 
tense, hemispherical swelling situated immediately upon the mastoid pro- 
cess and extending beyond its limits. The external auditory canal was so 
narrow that I was unable to obtain a view of the drum-membrane. The 
child, however, had never had a discharge from either ear. A free vertical 
incision gave exit to at least a drachm of thick healthy pus. By means of 
the probe it was ascertained that the mastoid process was extensively de- 
nuded of its periosteum. A tent was introduced into the wound, and left 
there until the following morning. 

Ten days later I learned from the attending physician that the external 
wound had healed, that the auricle had returned to its natural position, and 
that the child was as well as it had ever been. 

In the following case the pathology of the disease is by no means clear. 
While the periostitis of the mastoid process (including the posterior wall of 
the external auditory canal) constitutes the most striking feature of the dis- 
ease, it is difficult to resist the impression that an acute congestion of the 
antrum and pneumatic spaces constituted in reality the primary affection. 
At the same time the acuteness of the hearing in the ear of that side would 
indicate that, while the inflammation must have started in the tympanic 
cavity, it could scarcely have attained much vigor until it reached the remote 
mastoid region. ! 

1 Compare with Case XXIX, (on p. 338), which resembles this one in many respects. 



DISEASES OF THE EAE. 357 

Case XLVII. — Male, twenty-three years of age, student, healthy. De- 
cember 5, 1873. About one week ago he began to suffer from pain in the 
left ear. The pain has been steadily increasing and is now so severe as to 
deprive him of sleep. It involves the entire left side of the head. Marked 
tinnitus. No noticeable deafness (watch heard a distance of seven inches). 
Motion of the lower jaw somewhat painful. External auditory canal (L.) 
red, dry, and swollen, especially along the posterior wall and in close prox- 
imity to the drum-membrane, which is almost concealed from view by the 
swollen tissues of the canal. Skin covering the mastoid process red, swol- 
len, and very tender upon pressure. Angle behind the ear obliterated by 
the swelling of the subjacent parts. Ordered five leeches to mastoid 
region, and rest in bed ; also poultices, if pain persists. 

December 12th. — Leeches gave entire relief, and appetite soon returned. 
Ordered elixir of iron and quinine, to be taken for a week or ten days. 
No otorrhcea, but meatus filled with desquamated moist epithelium. 

A secondary mastoid periostitis, dependent upon a primary acute in- 
flammation of the external auditory canal, is seen quite often in practice. 
The following case, in which the too free employment of chromic acid in the 
meatus supplied the necessary exciting cause, may serve as an illustration 
of such a secondary periostitis. 

Case XLVLLL. — Boy, thirteen years of age, well nourished. March 4, 
1873. Discharge from the left ear since infancy ; at times admixed with 
blood. Occasional tinnitus. Membrana tympani destroyed. A small but 
rather firm mass of granulation-tissue springs from the upper and posterior 
portion of the tympanic cavity, in the vicinity of the entrance to the antrum. 
A very small crystal of chromic acid, attached to the moistened end of a 
slender middle-ear probe, was applied to the most prominent portion of 
the mass, and the patient was ordered to syringe out the ear two or three 
times daily with a lukewarm weak solution of carbolic acid ( t> . Acid, car- 
bol., 3 iij., aquse, 3 ij. M. S. — Half a teaspoonful to a pint of lukewarm 
water). 

March 8th. — Discharge decidedly less. Chromic acid application re- 
peated. 

March 12th. — Forty-eight hours after the last application of chromic 
acid, the patient began to suffer from quite severe pain in the ear. The pain 
continued without remission up to this morning, when it diminished ap- 
preciably in severity. The mastoid integuments are red and swollen, and 
there is tenderness on pressure. The walls of the meatus are also swollen 
and tender on pressure. Four leeches to be applied to the left mastoid 
process, and, after the bleeding has ceased, hot poultices. 

These measures relieved the patient entirely of his pain, and arrested 
the further progress of the inflammation. 



358 DIAGNOSIS AND TKEATMENT OF 



Analysis of Symptoms. 

In the preceding pages I have endeavored to show that the acute affec- 
tions of the mastoid process are susceptible of being arranged in groups or 
classes, in accordance with the degree to which particular regions of the bone 
are affected, and also in accordance with the nature of the lesions produced. 
At the autopsy table it is a perfectly easy matter to distinguish between these 
different types of mastoid disease, but at the bedside, unfortunately, it is very 
difficult, and often impossible, to recognize any such distinctions. How- 
ever, so far as the treatment of this class of diseases is concerned, it is of 
the greatest importance that we should be able to judge, in any given case, 
what parts of the mastoid process are involved in the inflammation, to what 
stage it has progressed in each of these parts, and finally to what extent 
neighboring organs are involved in the disease. As our task in diagnosis 
relates chiefly to the determination of these different points, I have thought 
that an analysis of the symptoms presented by the several forms of mastoid 
disease, would afford the best means of showing how far they may safely 
be trusted as indicators of certain lesions in certain localities. 

Pain. — In all the acute forms of mastoid disease pain is the most promi- 
nent, and, at the same time, the most constant symptom. In its general 
character it is at first precisely like that which is observed in an ordinary 
attack of acute inflammation of the middle ear. Afterward, the character 
of the pain changes, and the features which distinguish it from the pain of 
the more strictly tympanic inflammation become apparent. Thus, for ex- 
ample, in the latter form of disease the pain is of shorter duration, and is 
confined more particularly to the ear and its immediate surroundings, while 
in mastoid diseases it is apt to be referred to the entire side of the head as 
well as to the immediate surroundings of the ear. In some cases the pain 
is referred chiefly to the upper part of the side of the head. In others the 
patients describe it as shooting into the eye of the side affected. In others 
still, it is referred to the back of the head. During the night it is usually 
more severe than during the day. If it persists despite the various anti- 
phlogistic measures that usually relieve the pain which accompanies the 
more strictly tympanic type of inflammation, — such measures, for example, 
as paracentesis of the membrana tympani, the liberal use of leeches, and 
hot applications, — we may assume that either in the antrum itself, or in 
the adjacent pneumatic spaces, an inflammation is going on, which threatens 
serious damage to important organs, unless speedily checked. The severity 
of the pain in comparatively distant parts of the head (frontal, parietal, and 
occipital regions) has always appeared to me to indicate in a measure the 
degree of local meningeal irritation, which the subjacent mastoid inflamma- 
tion has set up. 



DISEASES OF THE EAR. 359 

Tenderness, redness, and swelling of the skin covering the mastoid process. 
— The changes which take place in the mastoid integuments furnish us with 
a valuable means of learning what is going on in the underlying bone. 
Their value, however, depends upon the relation which they bear to the 
progress of the disease in other respects. In an acute inflammation of the 
middle ear, slight tenderness, and perhaps even redness, of the mastoid in- 
teguments may develop as early as on the second or third day of the attack, 
and we may interpret these symptoms as an indication that not only the 
antrum but even the pneumatic spaces are congested, provided the condi- 
tion of the external auditory canal renders it improbable that the inflamma- 
tion has travelled directly from this region along the anterior surface of the 
mastoid process. This rapid development of congestive phenomena in the 
mastoid integuments also affords good evidence, in any given case, that 
sclerosis of the bone does not exist. In cases where we are in doubt as to 
the origin of the congestion, — whether from an extension of an inflamma- 
tion of the cells, or from an extension of the periostitis or cellulitis of the 
external auditory canal, — we must depend upon the history of the case, and 
also, in some measure, upon the topographical limits and severity of the pain 
experienced by the patient, for additional light in arriving at a correct con- 
clusion. In examining the skin that covers the mastoid process, we must re- 
member that, in a few individuals, a small lymphatic gland lies directly upon 
the body of the bone, and that this gland is apt to swell and become tender 
some time before the pneumatic spaces participate in the inflammation of the 
middle ear and antrum. The recognition of the presence of a small, movable 
nodule beneath the skin should prevent us from mistaking this condition 
for a tenderness of the mastoid integuments, in the ordinary sense of the 
term. On the other hand, there are perhaps two spots where such tender- 
ness is apt to show itself early. These are, first, a point near the centre of 
the base of the process, about on a level with the external orifice ; and, sec- 
ond, a point on the posterior aspect of the bone, perhaps half an inch above 
its tip. Both of these points correspond with openings of canals for mas- 
toid emissary veins. Tenderness on pressure at these points affords good 
evidence that the inflammation is spreading in an outward direction from 
the antrum. Finally, when the mastoid integuments begin to pit on pres- 
sure, we may draw the conclusion that the congestion of the deeper struc- 
tures has reached a stage from which it is not likely to recede without the 
development of a certain amount of free pus. Beyond this point, however, 
we are not yet able to go in formulating our conclusions. 

Sometimes the redness, tenderness, and swelling extend beyond the 
limits of the mastoid process. Thus, for example, the soft parts lying 
above and even in front of the auricle, may become swollen and more or 
less tender ; ?,nd the same condition often develops in the direction of the 
occiput. These lesions, however, are not so significant as those which show 
themselves below the mastoid process. The order in which this series of 



360 DIAGNOSIS AND TREATMENT OF 

changes takes place, is usually the following : first, tenderness on pressure 
over the central portion of the base of the mastoid process ; second, diffuse 
redness and swelling of the mastoid integuments ; third, very marked ten- 
derness of the cervical glands and other tissues lying below the mastoid 
process, on the side of the neck ; fourth, pain in this region when the head 
is moved, — the patient carrying his head as if he had a stiff neck ; fifth, the 
matting together of all the inflamed tissues below the mastoid process into 
a solid, flattened cake, over which the skin presents an almost erysipelatous 
appearance. When, for a period of several days, or perhaps even for two 
or three weeks, the symptoms of the disease have been pointing more and 
more decidedly toward the existence of acute inflammatory changes in 
either the antrum or the pneumatic spaces, the rather rapid development 
of the phenomena just enumerated may be confidently interpreted in one 
of two ways, viz., either as the expression of a phlebitis of the mastoid 
emissary vein (J. Orne Green), or as an indication that pus is actually 
working its way outward toward the surface (either along the bony canal 
which belongs to this vein, or along that which contains the facial nerve). 

In cases in which we can exclude a periostitis by extension from the 
auditory canal, tenderness on pressure, redness, and swelling of the mastoid 
integuments afford the best of evidence that inflammatory changes are go- 
ing on in the subjacent pneumatic spaces. The absence of these condi- 
tions, however, does not warrant us in drawing the conclusion that the 
more remotely situated antrum is not seriously involved. l In individuals 
who have been subject to chronic purulent inflammation of the middle ear, 
we may, as a rule, assume that the mastoid process is in a sclerosed condi- 
tion, and that consequently there are no pneumatic spaces to which the in- 
flammation may extend. The absence of redness, swelling, and tenderness 
of the outer integuments in such cases is therefore what we should expect ; 
and we may even interpret it as corroborative evidence of the existence of 
such a sclerosis. The practical deduction to be made from these facts is 
this : In cases of protracted, deep-seated pain, we must not wait for the de- 
velopment of these external manifestations of disease before we resort to 
the operation of perforating the bone ; the decision to operate should be 
based upon a variety of circumstances connected with the progress of the 
case, and not upon any one group of symptoms like that which we have 
just been considering. 

Finally, the symptoms referred to possess no value as means of deter- 
mining whether the pneumatic spaces are simply congested or whether 



1 Moos reports a case (Archives of Ophthalmology and Otology, Vol. III., p. 188), 
in which, during life, there were no evidences of mastoid disease beyond the existence 
of severe and persistent deep-seated pain in the region of the ear. At the post-mor- 
tem examination the cell -structures were found in a carious condition. Death oc- 
curred from exhaustion. 



DISEASES OF THE EAR. 361 

pus has already formed in them. If the tenderness, redness, and swelling 
are very marked, we may lean toward the belief that pus has already 
formed, rather than toward that which implies a simple congestion. 

Tenderness on pressure and swelling in other parts of the head. — I have 
observed this symptom several times. In one case, for instance, the patient 
called my attention to a spot of marked tenderness on the very top of the 
head. In the course of a few days a circumscribed swelling appeared at 
this spot, and then very slowly the swelling and tenderness both disap- 
peared, though not until after the mastoid affection proper had almost got 
well. In several cases I have observed phenomena of the same nature mid- 
way between the occipital protuberance and the mastoid process. In two 
of my cases this metastatic inflammation went beyond the stage of tender- 
ness and infiltration of the tissues, and terminated in the formation of an 



^Pn.c. 




St. m . f 

Fig. 25. — Section of the temporal bone showing the relations of the antrum to the facial canal. A = 
■antrum ; Pn.c. = pneumatic cells : St. m. f = stylo-mastoid foramen, or orifice of facial canal. 

abscess on the side of the head, at some distance from the area of mastoid 
inflammation. In two of Dr. Simrock's cases of mastoid disease, which I 
had the privilege of examining, such a metastatic abscess had developed in 
the temporal region. In all cases of this nature, we must assume that some 
irritating products of the mastoid inflammation are carried either along the 
venous or along the lymphatic network of vessels, to some remote spot on 
the head, where they soon give rise to an acute inflammation which may at 
times eventuate in the formation of an abscess. 

Facial paresis or paralysis. — When we consider how near the antrum is 
to the canal containing the facial nerve (see Fig. 25), we can no longer 
wonder that it should often become affected in the course of an inflamma- 
tion of this cavity. The development of such a paresis or paralysis of the 



362 DIAGNOSIS AND TREATMENT OF 

facial nerve simply furnishes a valuable means of estimating how far what 
was primarily an inflammation of the mucous membrane of the tympanic 
cavity and antrum has extended into the substance of the surrounding 
bone. Considered with regard to its prognostic value this symptom is not 
necessarily a grave one. In some cases permanent paralysis remains after 
the mastoid disease has entirely subsided ; while in others every trace of the 
paralysis disappears in the course of a few weeks. 

Body-temperature. — The height of the body-temperature may, as a rule, 
be taken as a measure of the degree of inflammatory disturbance in and 
around the ear. In a few cases, however, we may be led astray by the 
temperature record. Thus, for example, in Case XXXTV., the temperature 
was taken twice daily, during a period of thirteen days before the patient's 
death (probably from abscess of the brain), and yet it did not once rise as 
high as 100° F. In Case XVI., in which the cell-structures of the mastoid 
process were actively inflamed, the temperature rose to only 101° R In 
adults, therefore, we must not allow ourselves to be lulled into a sense of 
security by the fact that the body-temperature does not rise above the 
point which we might expect it to reach in even an ordinary attack of acute 
purulent inflammation of the middle ear. In children, the thermometer 
will be found more serviceable. 

Psychical phenomena. In four of my cases there was well-marked de- 
lirium. Three of the patients died, while the fourth (a young child) recov- 
ered. Drowsiness and coma, without delirium, were observed in other 
cases ; all of them terminating fatally. In all cases of delirium we may 
assume that a certain degree of meningitis of the convex portions of the 
brain has developed ; in those of coma, an effusion into the lateral ven- 
tricles, or an accumulation of inflammatory products at the base of the 
brain, may be assumed to exist. Both symptoms, therefore, are of grave 
import. 1 

Septicemic or pycemic symptoms. — Symptoms pointing to the entrance 
of pus or other poisonous matters into the circulation, are by no means 
common in cases of mastoid disease. At the same time quite a large per- 
centage of these cases die with symptoms of rather rapid consumption, and 
it is not unlikely that in some of these auto-inoculation may have taken 
place from some cheesy material imprisoned in the tympanum, antrum, or 
pneumatic spaces. In one of Schwartze's cases 2 the symptoms of pyemia 
were veiy pronounced, and yet eventually the patient recovered. 



1 Consult J. Orne Greeu : Brain Disease in its Relations to Aural Affections. Re- 
port of Boston City Hospital for 1877. 

2 Archiv f ur Ohrenheilkunde, Bd. X. , p. 186. See also the report of a fatal case 
of pyaemia, by Burnett, in the Philadelphia Medical Times, September 1, V: r H. 



DISEASES OF THE EAK. 



363 



Ocular symptoms. — Aside from strabismus in one case, and a difference 
in the size of the pupils in another, — both of which conditions did not man- 
ifest themselves until toward the end of the disease, — I have not observed 
any ocular symptoms in either the acute or the chronic varieties of mastoid 
disease. In the more severe cases, the patients are very apt to complain of 
pains that shoot into the eye of the side affected, and in one or two of these 
cases I have observed a slight conjunctival congestion. 1 



Redness, swelling and prolapse of the upper and posterior cutaneous ivall 
of the osseous portion of the auditory canal. — In acute inflammation of the 
antrum the seventy of the attack may be measured quite accurately by the 
character and extent of the changes which take place in the posterior and 




Fig. 26. — Horizontal section of the temporal bone, showing the relations of the antrum to the external 
auditory canal : A = antrum ; M = meatus auditorius exturnus ; T = tympanic cavity ; Pn.c = pneumatic 
cells ; L = labyrinth. 



upper wall of the meatus, near the drum-membrane. If a horizontal or 
slightly inclined section be made in such a mariner as to pass through this 
portion of the auditory canal and also through the antrum — as has been 
done in the accompanying cut taken from " Henle's Anatomy " — the proxim- 
ity of this cavity to the upper and posterior limits of the osseous auditory 
canal will be appreciated at a glance. In cases of chronic purulent inflam- 
mation of the middle ear the mass of bone lying between these two cavi- 
ties may assume such an ivory-like hardness that no inflammatory influences 
can traverse it. Thi^ possibility must be borne in mind, and in cases of 
suspected sclerosis of the mastoid process, associated with deep-seated 
pam, we must not expect to find the lesions which I have just described. 



Consult Moos : Archiv fur Ohrenheilkunde, Bd. XIV., p. 280. 



364 DIAGNOSIS AND TEEATMEJSTT OF 

In the majority of cases, however, we may attach very great value to the 
condition of this posterior and upper portion of the inner half of the 
canal. 

Treatment. 

In discussing the question of treatment I will consider separately the 
different measures which are known to exercise a controlling influence upon 
inflammatory affections of the mastoid process. 

In the first place, the application of heat and moisture, in the form of 
poultices, will often be found useful ; not because such hot applications 
possess any decided power to arrest the inflammation, but because they 
mitigate the pain in an appreciable degree. When the cervical glands and 
surrounding cellular tissue on the side of the neck become inflamed and 
matted together into a hard, flattened mass, poultices will be found very 
effective in removing the hardness and in promoting the absorption of the 
exuded material. 

Local depletion by means of leeches exerts a direct restraining influence 
upon the inflammation. In young persons they must be used with great 
caution, if used at all. In a strong, healthy adult they may be used very 
freely. In fact, it is not of much use to employ them in any other manner. 
It is comparatively rare that the application of three or four leeches does 
more than produce a temporary remission of the pain. Kecently I have 
obtained more positive results by applying as many as seven or eight 
leeches, and then, twenty-four hours later, applying three or four more. 
In these cases, however, the deep-seated pain and the tenderness behind 
the ear had existed for only a few days, and consequently the inflammation 
had probably not progressed much beyond the stage of congestion. Under 
such circumstances the free use of leeches may accomplish much. In the 
later stages of the disease, it is better, I think, not to use them except as 
an adjunct to other more radical measures. The angle behind the ear is 
probably the spot where the leeches may be applied to the best advantage. 
A few hours after the bleeding has ceased, we must expect to find the skin 
in the vicinity of the leech-bites red, swollen, and tender on pressure. As 
increased redness, tenderness, and swelling are, as I have already stated, 
valuable indications of an increase in the deep-seated mastoid inflammation, 
we may sometimes find it a difficult matter, after the employment of leeches, 
to decide what precise value should be attached to these symptoms. If in 
other respects the patient is worse, it is probably better to assume that the 
increased swelling, redness, and tenderness of the mastoid integuments 
signify a corresponding progress of the fundamental disease. On the other 
hand, if the patient seems to be better in other respects, we may attribute 
the increase in the outward manifestations of disease entirely to the leech- 
bites. 

A still more effective method of obtaining local depletion is that by 



DISEASES OF THE EAR. 365 

means of the operation known as Wildes incision. In this operation the 
skin and subjacent tissues, inclusive of the periosteum, are divided by an 
incision extending from the base very nearly to the apex of the mastoid 
process (the external wound measuring from three-fourths of an inch to 
one inch in length). If the patient's head is in the erect position, the point 
of the knife should be made to pierce the skin about on a level with the 
upper wall of the external orifice of the auditory canal. If we begin the 
incision higher up, we are apt to divide a branch of the posterior auricular 
artery, which usually crosses the bone at about this level. On the other 
hand, if we make the incision a little too far forward, we may nick this 
artery or incise it longitudinally, and so prepare the way for the develop- 
ment of a false aneuiism. 1 I believe that many a case of serious mastoid 

1 This accident happened in the following case : — 

Case XLIX. — Plumber, twenty-one years of age, and in the habitual enjoyment 
of good health. Two weeks before visiting the New York Eye and Ear Infirmary, he 
was attacked with the symptoms of an acute inflammation of the right middle ear, 
namely : deep-seated pain, throbbing, tinnitus, and deafness. When the pain became 
so severe that he could not tolerate it any longer, he visited the Infirmary. An exam- 
ination then revealed the fact that the outer canal was nearly obliterated by the swell- 
ing of its cutaneous walls, and that the skin over the mastoid process was red, swollen, 
and tender upon pressure. By gradual dilatation, the swelling of the 3anal was dimin- 
ished sufficiently for me to obtain a view of the deeper parts. In this way it was 
ascertained that the inner half of the canal was occupied by a mass of granulation- 
tissue, the removal of which was easily effected by the snare. To relieve the congested 
condition of the mastoid structures, a free incision was made in a vertical direction 
behind the ear, and of such a depth as to divide the periosteum. The incision having 
been carried rather nearer to the angle of the ear than is usual under such circum- 
stances, the withdrawal of the knife was followed by a small jet of arterial blood. The 
bleeding was arrested by a compress placed over the wound and held tightly in posi- 
tion by a suitable bandage. All efforts to place a ligature around the wounded vessel, 
or to control the bleeding by torsion, proved unavailing. 

This occurred on the 9th of April, 1873. Three days later I saw the patient a sec- 
ond time. I found that the edges of the wound had united by adhesion, and that the 
pain had been entirely relieved by the incision. At the same time an abundant puru- 
lent otorrhcea had established itself. 

On the 14th of April the resident surgeon noticed distinct pulsation over the mastoid 
region. 

On the 15th there was a circumscribed pulsating tumor, about the size of a hickory- 
nut. 

On the 16th the pulsation ceased altogether, and the tumor diminished perceptibly 
in size. An incision was made in the line of the former wound, and a rather firm, 
nearly spherical clot of blood was removed from a distinct cavity. The outer portion of 
the clot was found to be laminated in structure. 

As the hemorrhage recurred upon the removal of the clot, the cavity was stuffed 
with lint. 

On the 18th, the removal of the lint was again followed by an arterial jet, which, 
rendered it necessary to stuff the wound a second time and apply firm pressure by 
means of a compress and bandage. 



366 DIAGNOSIS AND TREATMENT OF 

disease might have been prevented from going beyond the congestive stage 
if this simple and perfectly safe operation had been performed more fre- 
quently at the beginning of the attack than has generally been the case. 
As Wilde was the first to call attention to the great practical value of deep 
incisions in acute mastoid affections, it is both proper and pleasant to retain 
the name of Wilde's incision for this operation. 

The establishment of an opening in the mastoid process constitutes un- 
doubtedly the most effective procedure thus far discovered for checking an 
inflammation in this region, or for preventing it from spreading to impor- 
tant organs in the neighborhood. In some cases the beneficial effects of 
the operation are clearly to be attributed to the fact that a free outlet is 
thereby afforded to encaged products of inflammation. In other cases the 
benefit derived from this procedure can only be explained on the assump- 
tion that the establishment of a new centre of inflammation, in close prox- 
imity to that which called forth the operation, produces a strongly deriva- 
tive effect, and so checks the original disease. 

The first point of importance in connection with this operation is this : 
we should have in our minds a reasonably clear conception of the circum- 
stances which render its performance desirable. Thus, for example, in a 
case of acute origin, we may be guided by the following rule : 

In the early stage of the disease, when there is persistent and rather se- 
vere deep-seated pain, perhaps involving the entire side of the head as well 
as the parts immediately surrounding the ear, and when there is tenderness 
on pressure over the mastoid process and possibly also a little redness of 
the skin, we should apply to this region from four to eight leeches, accord- 
ing to the age and vigor of the patient. If the loss of blood has not pro- 

The compress and bandage were removed the following day, but the lint stuffing 
was left to ulcerate its way out. 

The patient subsequently made a rapid and good recovery. 

In regard to this case of traumatic aneurism, I would say, that the rarity of its 
occurrence in this particular locality is simply owing to the fact, that, when it becomes 
necessary to incise these parts, the incision is almost invariably made more posteriorly 
than in the present case. In this instance I purposely departed from the prevailing 
rule in order to ascertain a fact of some practical importance. In fully half of the 
cases of this kind, I have noticed that the loss of blood which ensued was exceedingly 
small, — much smaller than, in my opinion, was desirable,— and I believed that, to ob- 
tain uniformly a greater loss of blood, the incision should be carried close up to the 
angle where the skin is reflected from the mastoid process upon the auricle, and where 
the posterior auricular artery and vein lie. The experience gained in the present case 
shows, however, that the danger of simply nicking the artery, instead of dividing it, 
and the difficulty of placing a ligature around the divided vessel, deeply situated as it 
is among very firm and unyielding tissues, are good and sufficient reasons why the es- 
tablished rule should not be departed from. 

(Dr. Charles J. Kipp, of Newark, N. J., reported a very similar case to the New 
York Ophthalmological Society at one of its meetings in 1873. The hemorrhage, in 
his case, was so serious as to threaten the life of the patient.) 



DISEASES OF THE EAR. 367 

duced any decided depressing effect upon his strength, the after-bleeding 
may be allowed to continue for half an hour or one hour. Warm fomenta- 
tions should then be kept applied to the mastoid region for several conse- 
cutive hours. If these measures fail to afford the desired relief, or if after 
the lapse of say twenty-four hours, the pain is found to be as active as it 
was before the leeching, a Wilde's incision should then be made without 
further delay. Finally, if this procedure also fails to relieve the pain, or 
if it relieves this symptom only temporarily, an opening should as soon as 
possible be established in the mastoid process. The nature, location, and 
depth of this opening will be considered farther on. 

The question might be raised by some physicians whether they should 
interpret this rule as meaning that, in the event of their failing to alleviate 
the pain by the other measures enumerated, they ought to perforate the 
mastoid process as early as on the fifth or sixth day after it has shown signs 
of being inflamed. As a matter of course, the rule is not to be followed 
blindly, nor without due consideration of all the facts connected with the 
case. Circumstances undoubtedly may exist which would render it desira- 
ble to modify the rule. For instance, the condition of the external audi- 
tory canal or drum-membrane on the fifth or sixth day may be such as to 
render it advisable that we should then devote special attention to this 
region before we adopt the conclusion that the mastoid process should be 
perforated. But if no such valid contraindicating reasons exist, I believe 
that the sooner the operation is performed, the better it will be for the pa- 
tient. In actual practice, it will rarely happen that, in following the rule 
which I have laid down, and which is essentially the same as that which I 
published in 1873, 1 we shall find ourselves called upon to perforate the 
bone as early as on the fifth or sixth day. The vigorous employment of 
leeches is usually followed by a remission of the pain for from one to two 
or three days ; and a still more protracted lull is apt to follow Wilde's inci- 
sion. In this way the question of an operation upon the bone does not 
usually present itself for serious consideration before, say, the tenth day. 

A question far more difficult to solve than the one which I have just 
been discussing is that which relates to the class of cases in which there is 
no tenderness on pressure over the mastoid process, no redness of the skin 
covering this bone, and no perceptible swelling. The persistent deep- 
seated pain, the previous history of the case, and the appearances presented 
by the drum-membrane or neighboring parts, are the only data upon which 
we can base an opinion with regard to the advisability or non-advisability 
of perforating the bone. As these data vary greatly in the different cases 
of this class, no such general rule can be formulated for them as for those 
cases in which the outward manifestations of mastoid disease are plainly visi- 
ble. We shall not often go astray, however, if we assume that the mastoid 

'Archives of Ophthalmology and Otology, Vol. III., 1873. 



368 



DIAGNOSIS AND TREATMENT OF 



process is sclerosed, and that consequently the outward manifestations of 
disease observed in the acute cases (without sclerosis) are not to be ex- 
pected. In some of these cases we may succeed in restoring an adequate 
outlet through the obstructed natural channel tympanic orifice of antrum. 
As a rule, however, the establishment of an artificial opening in the bone 
affords the patient the best chance for his life. 

Thus far I have spoken only of the circumstances under which it is de- 
sirable to perforate the mastoid process. I will now mention briefly those 
under which it is better not to interfere. Thus, for example, the physician 

may not be called to see the pa- 
tient until after coma has set in, 
or until pyaemia has developed ; or 
he may find the patient far advan- 
ced in consumption. Under such 
circumstances the chances of doing 
the patient any good by an opera- 
tion are so slight, that he may with 
perfect propriety advise against it. 
So far as the operation itself is 
concerned, it may be described as 
follows : 

A free vertical incision should 
be first made through the skin and 
periosteum covering the mastoid 
bone. The condition of the latter 
should then be noted. If it be soft 
or roughened, an attempt should 
be made to break through the outer 
lamella by firmly pressing upon it 
with the end of a steel director. If 
pus be found between the perioste- 
um and the bone, search should be 
made with a bent probe for a sinus 
through which the pus may have found an escape from the mastoid cells. If 
such an one can be found, the drill should be applied at this point, and the 
existing channel or fistulous opening should simply be enlarged. If no open- 
ing be found, the periosteum should be dissected from that portion of the 
mastoid process which is situated immediately behind the external auditory 
canal, and the drill 1 should be applied at a point a quarter of an inch distant 




Fig. 27. — Bone drills. (Natural size.) 



1 Of the two drills represented in the cut, I almost always employ the larger one. 
Schwartze gives the preference to small bone gouges and chisels, which he uses in 
connection with a mallet. I fail to appreciate, however, in what respect these instru- 
ments are superior to the drills represented above. 



DISEASES OF THE EAK. 369 

from the canal and a little below the level of its upper wall. The instrument 
should then be rotated in a direction inward, forward, and a little upward — 
that is, nearly parallel with the canal. The depth to which it should be car- 
ried will vary in different cases. In the acute cases the aim should be to reach 
the peculiar cell-structure of the mastoid process. Ordinarily, it will be 
reached at a slight depth. The drill should then be withdrawn and the 
steel director may be used to break down the bony septa. In infants the 
antrum is situated so near the outer surface of the bone that very little 
effort will be required to establish the desired opening. If sclerosis of the 
bone be found, we should endeavor to bore a channel down to the antrum. 
In performing this operation, however, we must observe certain precautions. 
In the first place, the lateral sinus may occupy an unnatural position ; that 
is, its bony groove may encroach to so great an extent upon the body of 
the mastoid process as to he directly in the path of the drill. It is there- 
fore important to manipulate the instrument in such a manner that it shall 
not injure, even though it may encounter, this vein. The simplest way of 
accomplishing this is to keep the forefinger of the right hand (if that be 
used in operating the drill) constantly pressing against the neighboring 
surface of the bone. In this way (by counter-pressure) the danger of in- 
juring the lateral sinus will be almost entirely removed. 1 The next ques- 
tion of practical importance relates to the depth to which we may safely 
carry the drill in our efforts to reach the antrum. Schwartze says : " Never 
go deeper than twenty-five millimetres." Unless the case is of such a grave 
character that we may safely run some risk, it is better, I believe, to place 
the extreme limit of depth at twenty millimetres, or about three-quarters 
of an inch. The risk to which I have reference is that of plunging the 
point of the drill into some portion of the labyrinth. 

Some writers lay stress on the importance of sending a stream of tepid 
water from the artificial opening, first into the middle ear and then out 
through the external auditory canal. This practice has never commended 
itself to my judgment. The washing out of either the antrum (if filled 
with cheesy or foul pus) or the cavity of an abscess located in the body of 
the mastoid process, by means of a nozzle or tube that is considerably 
smaller than the artificial channel in the bone, seems to me to be a very 
proper procedure ; but to use force, in order to make the water escape by 
way of the external auditory canal, does not appear to me to be good prac- 
tice. In other respects the after-treatment is to be precisely like that of 
any other open wound. Drainage-tubes, I am confident, can perfectly well 
be dispensed with. 



1 See history of case in which I encountered this vessel in boring through a 
sclerosed mastoid process. Out of fifteen operations this is the only one in which I 
have encountered the lateral sinus. 
24 



CHAPTER X, 

MISCELLANEOUS CONDITIONS OF THE DKUM-MEMBBANE, OSSI- 
CLES, AND TYMPANIC CAVITY. 

Atrophy of the membrana tympani. — In the condition known as atrophy 
of the membrana tympani, we find this membrane usually thin and trans- 
parent, and at the same time more concave than natural. In its slighter 
degrees one may very easily fail to recognize this condiljion. In such doubt- 
ful cases of atrophy the behavior of the membrane under inflations of the 
middle ear will often aid us very materially in arriving at a correct diagno- 
sis. Thus, for example, if atrophy exists, an undue convexity of the mem- 
brane (after the inflation) and a certain peculiar opacity (like polished steel 
just breathed upon), due to the undue stretching of the outer dermoid sur- 
face of the membrane, will at once attract the attention of the observer. 
Furthermore, I think one is less likely to err in estimating the degree of 
unnatural convexity than in determining that of undue concavity. After in- 
flation of the middle ear, a non-atrophied drum-membrane should present 
but a very slight degree of convexity, even when the Eustachian tube is so 
obstructed as to keep the air encaged in the cavities of the middle ear. The 
lesser degrees of atrophy are very common. A high degree of this condition 
is observed in cases of chronic naso-pharyngeal catarrh, with hypertrophied 
tonsils and follicular enlargements. Prolonged undue atmospheric pres- 
sure upon the outer surface of the membrane is the cause of the atrophy in 
these cases. In cases of sclerosis of the mucous membrane of the middle 
ear, we find an atrophy of the membrane which seems to differ from that 
which I have just described. The membrane is apparently just as thin and 
transparent as in the other form of atrophy, but it seems to retain its sub- 
stantia propria unchanged ; for the membrane is at most very little sunken, 
and inflation does not cause it to bulge to an unnatural extent. This con- 
dition, as it appears to me, may be explained in the following manner : 
The atrophy is probably limited to the mucous lining of the membrana 
tympani ; though perhaps the process of contraction may at the same time 
interfere with the circulation of blood in this membrane to such an extent 
as to diminish materially its entire blood-supply. 

So far as the diagnosis is concerned, the only other condition that might 
be mistaken for atrophy is a newly produced drum-membrane. The pres- 



DISEASES OE THE EAR. 371 

ence of other evidences of an otitis media purulenta, either in the affected 
ear, or in its fellow, or the history of a previous otorrhcea, would favor the 
diagnosis of a cicatricial membrane ; while the absence of these, especially 
if the condition of the throat and Eustachian tube pointed to the previous 
existence of active disease in these localities, would favor the diagnosis of 
simple atrophy. 

No treatment of which I have any knowledge is likely to restore an atro- 
phied drum-membrane to its normal state ; nor do I know of any proced- 
ure that will render it less elastic, that is, more capable of responding to 
the vibrations of the air. I have not the slightest faith in frequently re- 
peated incisions. 

Horny growth of the membrana tympani. — I have seen but one case of 
this peculiar pathological condition. The patient, a man thirty-six years 
of age, was admitted to the New York Eye and Ear Infirmary on the 21st 
of June, 1871. He stated that fourteen years previously, during exposure 
to severe weather, he first began to be troubled with noises and slight deaf- 
ness in both ears. These symptoms had continued since, though at times 
they were less marked than at others. In both cases the watch could only 
be heard at a distance of two inches ; in conversation with him, however, I 
was not obliged to raise my voice appreciably. On inspection I found the 
external auditory canal filled with hard inspissated cerumen. To facili- 
tate the removal of these hard plugs of wax, the patient was instructed to 
fill the ears night and morning with a warm solution of bicarbonate of 
soda (gr. x.— f j.). Three days later the cerumen was easily removed by 
syringing. On examination, the drum-membranes then presented the 
following appearances : On the left side there was nothing specially note- 
worthy ; on the right, the upper three-fourths of the membrane was occu- 
pied by a flattened, sharply outlined mass of a pale yellow or yellowish 
white color. It stood out from the level of the membrane to a distance of 
a little more than a millimetre, and terminated, throughout its entire lower 
border, with abrupt edges. Along its upper and anterior boundary, the 
mass became gradually merged in the skin of the auditory canal. Its sur- 
face was smooth and slippery, and, when touched with the probe, conveyed 
the impression of being quite hard. The portion of the membrane that was 
not covered by the mass, was of a uniform milky appearance, similar to that 
which is frequently observed in cases of chronic catarrh. With a view to 
obtaining more light on the nature of this mass, I instructed the patient to 
continue the use of the soda solution for another week. At the end of this 
period I found the mass practically unchanged. Its surface had been ren- 
dered slightly soft by the prolonged soaking, but I could discover no other 
change. 

My interpretation of this case was, that the mass represented a horny 
growth from the dermoid layer of a limited portion of the membrana tym- 



372 DIAGNOSIS AND TBEATMENT OF 

pani. It has also seemed to me probable, or at least possible, that the long- 
continued pressure of a ceruminous plug might have been the exciting 
cause. 

Vascular growth of the membrana tympani. — In a young lady, twenty-two 
years of age, who consulted me for a slight general impairment of her hear- 
ing, I found in the posterior superior quadrant, just behind the short pro- 
cess of the hammer, and encroaching a little upon this bone, a small, 
rounded, bright-red fleshy mass, about as large as a No. 12 shot {i.e., about 
a millimetre or a millimetre and a half in diameter). It appeared to be 
quite soft, and was freely movable when manipulated with the probe ; at 
the same time it was not pedunculate. In the present instance this vascu- 
lar nsevus possessed no significance beyond that of a mere pathological curi- 
osity ; and yet there is no good reason why, in this case, at some future day, 
a more extensive tumor of this kind may not be found growing from the 
membrana tympani. 

Deformed drum-membrane. — The following case illustrates one of the 
many transformations in the relations of the parts which a prolonged puru- 
lent inflammation is capable of producing : 

The patient — a girl about twenty years of age — stated that she had had 
a discharge from the left ear for a period of several years, but that two 
years ago it ceased entirely. Since then she had simply been conscious of 
a certain degree of deafness in the affected ear. An examination revealed 
the following state of things : 

The meatus was quite natural in its outer two-thirds ; beyond this 
point it rapidly diminished in size and terminated in a very small (diameter 
— 2 mm.), circular, translucent membranous plate, which occupied, so far 
as I could judge, exactly the same position as that which the drum-mem- 
brane should occupy. Its edges merged imperceptibly into the surround- 
ing tissues. There were no landmarks of any kind by means of which I 
might decide whether this membranous structure was a remnant of the 
membrana tympani, or a membranous transformation of newly formed in- 
flammatory tissue. Its situation certainly favored the former view. The 
hearing-power in the L. ear was fair. 

Absence of the hammer. — In examining the ear of a patient at the New 
York Eye and Ear Infirmary, I was very much surprised to find that the 
drum -membrane, which seemed to be perfectly constructed in all other re- 
spects, totally lacked its manubrium mallei. On questioning the man, I 
ascertained that about four years previously an operation had been per- 
formed (under chloroform) on that ear, but that it had failed to relieve him 
of his deafness. From this statement, and from the condition observed, I 
drew the inference that excision of the entire hammer had probably been 




DISEASES OF THE EAR. 373 

performed. In this case I searched very carefully for a cicatricial region 
in the location which the manubrium should occupy, but I failed to find 
the slightest difference between this portion of the membrane and the sur- 
rounding portions. 

Hook-shaped manubrium mallei. — The peculiar deformity observed in the 
following case was probably of congenital origin. The patient, a boy thir- 
teen years of age, was admitted to the New York Eye and Ear Infirmary on 
the 15th of May, 1872. When three years old he had passed through an 
attack of scarlet fever, which left him with a double 
otorrhcea. On the right side the discharge had contin- 
ued up to that time without interruption ; on the left 
it had entirely ceased about one year previously. On 
examination I found the end of the handle of the ham- 
mer, on the left side, curved from behind forward, in 
the manner shown in the accompanying cut. The mem- 
brane itself was opaque and somewhat mottled, but it ^^"^"111^ ^ 
presented no traces of ever having been perforated. 
There was also nothing to indicate that a fracture had ever occurred. On 
the opposite side the drum-membrane and handle of the hammer had 
been entirely destroyed, so that it was no longer possible to institute a com- 
parison between the two sides. The boy was in robust health, and pre- 
sented no signs of ever having had rickets. * 

Ruptures of the drum-membrane. — In my experience, ruptures of the 
membrana tympani, from concussion of the air in the external auditory 
<?anal, are comparatively rare. I can find only five instances of this lesion 
in my records. In two of these the rupture was produced by a "box" on 
the ear, in two others the patients seemed to be unwilling to divulge the 
cause (one of them, however, stated that she fell down stairs, but I was sat- 
isfied that she was trying to deceive me), and in the fifth case the patient 
was struck on the ear by a snowball. In two cases the rupture ran di- 
rectly downward and a little backward, iu a line directly continuous with 
the handle of the hammer. In other words it consisted in a mere separa- 
tion of the radial fibres of the substantia propria. In the third case it ran 
from a point near the periphery of the posterior superior quadrant directly 
downward in a straight line to a point near the periphery of the posterior 
inferior quadrant. In the fourth case the perforation ran in a slightly 
•curved line from the lower limit of the posterior superior quadrant (mid- 
way between the umbo and the periphery) to the central portion of the an- 
terior inferior quadrant. Finally, in the fifth case, the rupture occupied 
the posterior inferior quadrant and consisted of an irregularly shaped open- 

1 A case of abnormally bent manubrium mallei has been reported by Buhl and Hub- 
rich in the Monatsschrift fur Ohrenheilkunde, II., 1, January, 18G8. 



374 DIAGNOSIS AND TREATMENT OF 

ing with jagged edges. In three cases the appearance presented by the 
rupture was simply that of a reddened line, without any visible solution of 
continuity, while the parts were at rest. In the fourth case there was slight 
gaping of the edges. In the case of the rupture produced by the impact of 
a snowball the opening showed no tendency whatever to close. I saw it as 
late as six months after the occurrence of the injury, and it was still in a 
gaping though perfectly dry state. In one case, a discharge of short dura- 
tion followed the injury. Finally, in two cases, hemorrhagic infarctions 
were found in the vicinity of the rupture. 

Other injuries have been observed by different authorities, but those 
which I have mentioned are the only ones with which I have had any per- 
sonal experience. 1 

• New-growths in the middle ear. — In this category I propose to consider 
only those new-growths which depart so markedly from the ordinary type 
of aural polypoid tumors that it would be scarcely proper to consider them 
in the section devoted to the proliferative form of otitis media purulenta. 
Of the benign growths, the bony and the vascular are the only ones that 
have come under my observation. 

Marked hyperostosis of the bony wall of the tympanum is, in my experi- 
ence, a very rare condition. I have seen but two instances of it, both of 
them in middle ears that had previously been affected with a chronic puru- 
lent inflammation. In the first case the bone in the neighborhood of the 
fenestra? had increased so greatly in size that the posterior half of the 
drum-membrane presented a tense, polished, convex outer surface, due 
to the pressure of the subjacent bony growth. The handle of the hammer 
marked the anterior limit of the tumor, and rested firmly against it. The 
anterior half of the drum-membrane seemed to be cicatricial in character, and 
abnormally sunken. The patient was sixty-two years of age, and said that 
he had been quite deaf for at least thirty years. In the second case a hemi- 
spherical bony mass, apparently about five millimetres in diameter at its 
base, overhung the tympanic orifice of the Eustachian tube (right ear). 
Posteriorly it touched the stump of the handle of the hammer (the drum- 
membrane had been completely destroyed). The mucous membrane cover- 
ing the tumor was still recognizable as a distinct, more or less succulent 
membrane. The patient was sixteen years old, and there had been a dis- 
charge from the right ear for a period of fully seven years. 2 



1 Consult, on this subject, Weir : Ununited Fracture of the Manubrium Mallei, 
Transactions American Otological Society, 1870; Schalle, in Archiv fur Ohrenheil- 
kunde, XII., p. 10 ; Burnett, in Transactions American Otological Society, 1872 ; Polit- 
zer, in Wiener Medical Presse, 1872; Biirkner : Archiv fur Ohrenheilkunde, XIV., 
p. 230; Shaw: Boston Medical and Surgical Journal, November, 1868; Turnbull, in 
Medical and Surgical Reporter, Philadelphia, February 22, 1879. 

2 Consult also Zaufal, in Archiv fur Ohrenheilkunde, II. , p. 48 ; Moos, in Archives 
of Ophthalmology and Otology, II., pp. 127 and 190. 



DISEASES OF THE EAR. 375 

Intratympanic vascular growths are probably encountered even more 
rarely than are those of a bony nature. So far as I can learn, there are 
but four instances on record in which a vascular tumor developed in a mid- 
dle ear whose drum-membrane was still intact, viz., one reported by 
Schwartze, 1 two by Weir, 2 and one by myself. 3 In Schwartze's case very 
few details are given. The left drum-membrane, which was otherwise 
white and lustreless, presented a pulsating point near the umbo. The 
pulsations were synchronous with the radial artery, and ceased during the 
performance of Valsalva's experiment. From the meagreness of the details 
given, it is not even quite clear that the case belongs in the present cate- 
gory. In both of Dr. Weir's cases, however, one of which I had the privi- 
lege of examining at my office, and also in my own case, the evidence of the 
existence of an intratympanic vascular growth is reasonably clear. In view 
of the rarity of tumors of this nature, I will give in full the histories of 
these three cases. 

Dr. Weir's first case. — "Mrs. J. A., get at. 35, was sent to me in Novem- 
ber, 1870, by Dr. J. T. Metcalfe, for deafness of the right ear, which had be- 
gun about a year previously, had rapidly increased during the past few 
months, and was associated with a disagreeable though regularly pulsating 
noise. There had been no pain or discharge. At times slight attacks of 
vertigo had been experienced. 

"On examination, H. D. right side=^-; left, normal. After I had re- 
moved a slight layer of cerumen, a remarkable appearance presented itself. 
The whole drum-membrane was evenly and intensely reddened and strongly 
pushed forward in a bulging manner, except along the line of the malleus, 
which was situated apparently in a depression, and was marked at its free 
end by a white spot, in strong contrast to the other parts of the membrane. 
The whole membrane pulsated visibly and strongly, especially so superiorly, 
where there was a broad light spot. The pulsation was synchronous with 
that of the carotids, and was arrested by pressure on the artery of the cor- 
responding side. No distinct vessels were to be seen on the membrane, 
only a general redness. By Siegle's tympanoscope the drum-membrane 
could be forced in but little, and the pressure only rendered the pulsation 
more broadly and decidedly marked, and particularly so near the inner 
side of the malleus. By the otoscopic tube the heart-sounds were dis- 
tinctly heard, but not so on the sound side. No air could be felt to enter 
the tympanic cavity by Valsalva's or Politzer's method, nor by the catheter. 
No redness or abnormal change was noticed in the external auditory canal. 

" Thinking at first that I had to do with an exaggerated case of bloody 
serum in the middle ear, paracentesis was resorted to at the middle of the 

1 Arch. f. Ohrenh., I., p. 140. 

2 American Journal of Otology, Vol. I. , p. 120. 

3 Ibid., p. 126. 



376 DIAGNOSIS AND TREATMENT OF 

posterior segment, giving exit to blood which rapidly filled up the canal 
and flowed to the amount of 3 j. in a few seconds, but was easily arrested 
by plugging the canal for a few moments with cotton. Attempts were 
made to inflate the tympanic cavity by the catheter, after bougieing the 
Eustachian tube up to its isthmus, but no air emerged from the puncture. 
On inspection no change in the appearance of the drum-membrane had re- 
sulted from the puncture, but three days later, when paracentesis was again 
resorted to, and after the cessation of a moderate hemorrhage, the drum was 
found collapsed and somewhat wrinkled ; the hearing also was found to 
have increased to ¥ 2 y. This improvement in hearing and condition of the 
drum-membrane only continued until the next day, and the pulsation was 
then felt as decidedly as ever by the patient, though to the eye it was much 
more feeble. I had by this time come to the conclusion that I had to deal 
with a vascular tumor in the middle ear, or that I had, according to 
Schwartze, a hypertrophied condition of the mucous membrane associated 
with an accumulation of bloody serum in the cavity. Leaning, however, to 
the first view, a consultation with Dr. Simrock, an acknowledged aural au- 
thority, was suggested and carried out. Dr. Simrock thought that the 
difficulty was due either to fluid in the middle ear, or, as he thought that 
he succeeded in forcing air through the Eustachian tube, that it was a col- 
lection of fluid in the tissue of the drum-membrane itself. A third puncture 
was made posteriorly, carrying the needle in until it reached the promon- 
tory — no air could be forced out. Convinced of the correctness of my 
diagnosis, on December 5th a fourth puncture was made with a large nee- 
dle, and a probe dipped in pure nitric acid was inserted through the open- 
ing into the middle ear. But little pain was occasioned by this treatment. 
As a result of the several punctures, it was noticed not only that after each 
the hearing-distance increased, but that the pulsation became less distinct. 
This subsidence became more and more permanent, but the cicatrices of 
the punctures, yielding under the pressure from within, protruded almost 
teat-like from the drum-membrane, and after this application of acid a mass 
projected through the opening there made, and, spreading out and pulsat- 
ing faintly, obscured nearly the whole membrane, and assumed a polypoid 
appearance in the course of a week. This mass was punctured and a probe 
dipped in liq. ferri persulph. introduced into its depths, blanching it at 
once. 

" The subsequent history is in brief this : the mass sprouting from the 
opening in the drum-membrane was with difficulty destroyed by the use 
of nitric acid applied, first, every second or third day for a number of 
times ; afterward, at intervals of one or two weeks (as the patient lived out 
of the city) ; and subsequently, as the tissue became tougher, by the use of 
the acid nitrate of mercury, which was carried, by means of a thin film of 
cotton around the end of a fine wire, through the tympanic opening into 
the cavity itself. At times considerable pain was caused by the applications, 



DISEASES OF THE EAR. 377 

but as a rule they were less distressing than would have been anticipated. 
Several attempts were made to extract pieces of the mass for microscopical 
examination, and the one or two small portions so obtained were reported, 
by Dr. A. H. Buck, to show nothing but scales of epidermis and debris so 
changed by caustics as to be unrecognizable. 

"By this treatment, the tumor, in the course of four to five months, was 
apparently destroyed, and it was observed that in the later cauterizations 
little or no hemorrhage occurred, and that when the punctures and applica- 
tions — for they were sometimes conjoined — were carried into the tympanic 
cavity, the sensation was given that that space was more or less filled with a 
solid tissue. No air at any time was felt in the middle ear. 

" On July 1, 1871, three weeks after the cessation of treatment, it is noted 
that H. D. =-fiy ; bottom of canal closed by a smoothly depressed, fleshy -look- 
ing membrane, still considerably though irregularly injected. No pulsa- 
tion whatever to be seen or heard by the physician, and only very slightly 
perceived by the patient. 

" August 4th. — Mrs. A. presented herself, on her way from Newport, stat- 
ing that she had had only occasional pulsation in the ear in the erect posi- 
tion, but always when in bed. On examination it was found that the mem- 
brane had changed from its former fleshy appearance to one more normal. 
Now the malleus could be defined ; the membrane itself was still irregu- 
larly patchy, of a pink hue in spots, but with some translucency. By the 
use of Politzer's inflation, for the first time air is heard to enter the middle 
ear by the otoscope. Ordered Valsalva's experiment to be practised at 
home. 

"November 14th. — Drum-membrane is quite normal in the posterior 
part. Malleus clearly seen. Anteriorly, two months ago, was seen a red, 
bulging spot, as if the tumor was returning there, but this to-day is not 
seen ; the drum-membrane at this point being now mottled with white 
bands running from the malleus to the periphery. Tube slightly open by 
Valsalva's method ; air readily enters. H. D.= ¥ 3 o to ^- ^° use Politzer's 
bag daily. 

"February 7, 1872. — H. T>.=-^. Hears pulsation only when in bed. 
Drum-membrane still mottled and sparsely injected. No evidence of return 
of tumor. 

" December, 1878. — No recurrence of the tumor. Reports herself as hear- 
ing well. Ear giving her no trouble whatever. As patient was met in the 
street, exact information could not be obtained." 

Dr. Weir's second case. — "A negro woman, thirty-five years of age, was 
seen by me December 8, 1870, with the history that for four years past she 
had had " beating noises " in the left side of her head, which were much in- 
creased by stooping, which position would also cause severe dizziness. 
Vertigo came on at times in the erect position. The hearing on the same 



378 DIAGNOSIS AND TREATMENT OF 

side had also failed, and on her visit to me was ^, while on the left side it 
was normal. She believed that her heart was affected, as she so distinctly 
and so persistently heard the sounds in her ear. There was, however, no 
cardiac lesion. She was much depressed and anxious by reason of her ear 
trouble. On inspection it was perceived that the posterior surface of the 
drum-membrane, and more especially its inferior portion, was of a reddish 
hue, with some vessels running over it, and that it was not only bulged out- 
ward, but that it visibly pulsated synchronously with the heart. Consider- 
able injection of the malleus was also present. The Eustachian tube was 
pervious. By Siegle's otoscope it was seen that a faint line half-way up the 
posterior segment was movable. Paracentesis was, therefore, resorted to, 
and blood rapidly filled the canal, but was readily checked by a mop of cot- 
ton left a few moments against the drum. Politzer's inflation being then 
used, air freely escaped through the opening in the drum-membrane, after 
which H. D.=^j. She was not seen again until June 1, 1871, when she re- 
turned with the statement that since the puncture she had been very much 
better, and her hearing had improved and kept in fair condition until a 
week previously, when the latter rapidly diminished. Now H. D. =£y. Left 
drum-membrane translucent everywhere, except at postero-inferior portion, 
where a roundish red spot, the size of a small pea, was seen projecting for- 
ward, but not pulsating. By Siegle's apparatus fluid line was again de- 
tected ; it was rendered more clear after Politzer's inflation had been suc- 
cessfully used. Projection outward apparently the same. 

" June 15th. — Paracentesis used for a second time, causing not only H. D. 
to rise to Jf , but also disappearance of the pulsating noise and redness. 
This absence of pulsation was noticed only a few days. 

" August 1st. — Ke turned with symptoms of dizziness, deafness, and pulsa- 
tion. Fluid seen in tympanic cavity. Eedness and pulsation in drum-mem- 
brane observed as at first. Paracentesis, with needle carried in until it was 
arrested by bony resistance. 

' ' November 7th. — Kepeated paracentesis. Says that after every puncture 
the sound is lessened in intensity. 

" December 11th. — Paracentesis twice in past week, and a probe wet with 
liquor ferri persulphat. also introduced. 

" She was not seen subsequently until February 18, 1873, when the tumor 
was seen projecting still on the posterior and inferior segment of the drum, 
pulsating, and of a red color. Dizziness complained of more than ever. 
H. D.=0. 

" Up to March 24th, paracentesis was performed three times, with the 
subsequent introduction of cotton wound around a cotton probe and dipped 
in acid nitrate of mercury. This kept the opening patent, and several appli- 
cations through it of a solution of chromic acid (100 gr. to 3 j.) were 
made. Pulsation scarcely seen, and heard much less distinctly by the pa- 
tient. Dizziness has also ameliorated. 



DISEASES OF THE EAR. 379 

" April 25th. — For the past three weeks she has been free from vertigo 
and pulsating noises. After a rest of two weeks after last state, a new and 
long slit was made in the drum-membrane, and the chromic acid freely applied 
in the drum-cavity by the cotton probe. Considerable swelling and dis- 
charge followed. This has nearly all subsided and she feels better in her 
head than she has felt in five or six years. She can now stoop down and do 
her work without any unpleasant pulsation. 

" June 25th. — Has had the paracentesis and chromic acid used but twice 
since last note. She has steadily improved, having had no pulsation and 
no dizziness until about ten days ago, when both were noticed after violent 
exertion. By the speculum the lower part of the drum was found to be 
quite normal, save a few cicatricial traces. At the upper part posteriorly 
and advancing a little forward on the roof of the external auditory canal, 
is seen a reddish mass about two lines wide and about three long, not pul- 
sating, but evidently an extension of the angioma. She was then going into 
the country, and promised to return to me in the autumn if any further 
symptoms arose. She, however, did not do so. I have recently heard of 
her death in 1875, from phthisis. 

" From her friends I learn that the noises in her ear slowly increased, and 
for several months prior to her death they caused her much annoyance and 
distress." 

My own case. — Female, setat. 33, anaemic in appearance, and with oedema 
of the lower extremities. March, 1871. Patient states that two months 
previously she began to be troubled with a peculiar noise in the right ear, 
resembling in character — as she described it — the croaking of a bull-frog. 
This noise came at regular intervals, synchronous, as she had noticed, 
with the heart-beat. She had never experienced pain in the ear, and could 
not remember ever to have had an otorrhcea. She had also never noticed 
any difficulty in hearing. On examination with the speculum and reflected 
light, the following condition of the parts was found : the meatus was nor- 
mal. The membrana tympani was moderately sunken. The handle of the 
hammer was whitish and sharply outlined. In the anterior superior quad- 
rant the membrana tympani appeared to be perfectly normal ; in the pos- 
terior superior quadrant it was so transparent that the long process of the 
anvil and head of the stirrup could be plainly seen through it. The en- 
tire lower half of the membrane presented a uniform and rather vivid red 
color, as if an exudation of blood or bloody serum lay upon its inner side. 
Such, at all events, was the diagnosis made at the time. Paracentesis was 
suggested, but the patient felt too weak and miserable to have anything 
done. 

On the 17th of September, 1873, patient presented herself at the New 
York Eye and Ear Infirmary for the second time. Her story then was that 
two years previously she experienced some pain in the right ear, and after- 



380 DIAGNOSIS AND TREATMENT OF 

ward observed that her bearing in that ear was very imperfect. From that 
time to this there had been a constant, pulsating, roaring noise in the af- 
fected ear. On examination it was found that she could no longer distin- 
guish the tickiag of the watch in the right ear. The membrana tympani 
was found to have undergone the following changes : the lower half of the 
membrane was still as brightly red as in 1871, but at the umbo, passing 
from before backward, the upper boundary line of the red region ran up- 
ward and backward, instead of straight across. The posterior half of the 
membrane — chiefly the lower two-thirds — was now markedly convex and 
pulsated synchronously with the pulse at the wrist. Suction with Siegie's 
apparatus gave marked relief for the moment, but the throbbing instantly 
returned when the instrument was withdrawn. I advised against active 
interference at that time. Patient never returned. 

Drs. Henry D. Noyes and Charles Laight verified the condition as de- 
scribed above. 

The points of interest and importance in this case may be briefly enu- 
merated as follows : 

1. The development of a new-growth in the middle ear, without any 
apparent cause for such growth (such as inflammatory irritation), either in 
the past history or in the present condition of the ear. 

2. The highly vascular character of the growth. 

3. The slowness of its development. 

The growths described in the preceding section were strictly intratym- 
panic, and furthermore they developed as it were spontaneously, without 
the provocation which an irritating purulent secretion is capable of afford- 
ing. In the case which I am about to describe there was ample provoca- 
tion for the development of some form of new-growth, but it is not clear 
why a strictly vascular growth — to which I have given the name of angioma 
cavernosum — should have been developed. Virchow, in his admirable 
treatise on tumors, devotes nearly two hundred pages to the consideration 
of vascular new- growths. He subdivides the angioma into a number of 
varieties, and applies the term cavernosum to that variety which is charac- 
terized by the existence of a network of blood-spaces, occupying the place 
and fulfilling the function of capillaries. According to his view, the arteries, 
in a growth of this kind, pour their blood into these spaces, from which it 
then passes into the veins, and so back into the general circulation. Such 
a growth as this, on a small scale, came to my notice in the practice of the 
New York Eye and Ear Infirmary. The patient, a mechanic, nineteen 
years old, was admitted as an out-patient on the 2d of April, 1870. He 
stated that from the time when he was seven years old to that time he had 
been affected with a discharge from both ears, and with frequent earaches. 
He had also been very much troubled by all sorts of noises in his ears. 
Eecently, he said, the noise in the left ear had been what might be termed 



DISEASES OF THE EAR. 381 

a pulsating, humming noise. It had been constant, but at regular inter- 
vals, corresponding apparently to the pulse-beat, it would become louder. 
Running upstairs, or any other violent exercise, would aggravate the noise 
very much. When he awoke, on the morning of the day on which he 
visited the Infirmary, he found his pillow covered with blood, which was 
still escaping from his left ear. The hemorrhage, which was not associated 
with even a trace of pain in the ear, continued throughout the entire fore- 
noon. Up to the time of which we are now speaking, the patient had 
never seen any blood in the discharge from either ear. On examination I 
found the left meatus filled with blood, partly fluid and partly clotted. I 
removed it by syringing out the ear, and then, on examination, I found that 
an oblong, dark-colored body, about the size of a small pea, was lying, ap- 
parently free, on the lower wall of the meatus. On closer inspection, how- 
ever, I discovered that it was attached by a loug and slender peduncle to 
the stump of the hammer. Dr. Robert F. Weir, in whose department the 
patient belonged, then divided the peduncle with slender scissors. No 
hemorrhage of any account followed. Almost immediately after its re- 
moval, the small growth was placed in a weak solution of chromic acid, the 
only preservative fluid that happened to be at hand at the time. Later it 
was transferred to a bottle containing alcohol. 

On the 25th of June the patient reported that, about the middle of May, 
the noises and the discharge had both returned, and had continued ever 
since. On examination of the left ear, I found a pinkish, vascular teat de- 
pendent from the stump of the hammer, and standing out in marked con- 
trast with the pale mucous membrane which formed the background. 

When the specimen had been sufficiently hardened in alcohol, it was 
imbedded in a mixture of wax and oil in equal parts. No special precau- 
tions were taken to place the tumor in such a position that the sections 
through it should include either the point of rupture or the stump of the 
peduncle ; but, fortunately, the middle sections included both of these 
points. ! I will not attempt in this place to give a minute description of the 
anatomy of this tumor, but will simply state that it was found to consist 
almost entirely of blood-vessels, which radiated from an irregularly shaped 
central cavity, and which were separated from each other by a network of 
of fibrillated connective tissue holding blood-corpuscles in its meshes. In 
some of the sections a large blood-vessel could be followed from the central 
cavity into the peduncle. In one of these, and also in other sections, the 
point of rupture could be distinctly traced from the central cavity to the 
periphery of the tumor. 

As the patient was asleep at the time when the hemorrhage took place, 
it must be assumed that it occurred through natural causes, operating 

1 Lithographic drawings of the microscopic appearances of this rare aural growth 
will be found in the Archives of Ophthalmology and Otology, Vol. II. , Part I. 



382 DIAGNOSIS AND TREATMENT OP 

■within the tumor itself. The constant pressure, which first produced the 
marked dilatation of the blood-vessels, and then an obliteration of their 
walls at different points, and eventually led to the formation of the large 
central cavity, must have been the chief agency in producing the final rup- 
ture of the peripheral portion of the tumor. Virchow's view, that an an- 
gioma is an independent new-growth of vessels, just as much as an exosto- 
sis is an independent new-growth of bone, finds strong confirmatory evi- 
dence in the fact that, six weeks after the original vascular tumor had been 
removed, a second one, of precisely the same vascular character, was found 
growing at the same spot. 

Malignant tumor of the middle ear. — Cancer or sarcoma of the middle 
ear is fortunately an extremely rare affection. Thus, for example, so far as 
I can learn, only one case of malignant disease of the middle ear had been 
reported yn this country, prior to the publication of a case by Dr. H. 
Knapp, in December, 1879. As the latter case was under my care for 
several weeks during Dr. Knapp's absence from the city, and as it is the 
only instance of malignant disease of the tympanum that I have seen, I will 
give here a brief sketch of it. 

The patient, a man thirty-seven years of age, and in poor physical con- 
dition, consulted Dr. Knapp on the 7th of May, 1877. The conditions 
which were found at that time are thus described by Dr. Knapp : 2 " Below 
and in front of his right ear there was a tumor the size of a hen's egg, 
which he had first noticed six or seven years previously. It had increased 
very slowly at first, but quite perceptibly during the last six months. His 
left ear was affected with chronic otorrhcea, without pain or any symptoms 
of irritation. His right ear never discharged, and he could always hear 
well with it until three days before he came to me. At that time he went 
to bed feeling and hearing as well as ever, but on awaking the next morn- 
ing, he found that he was deaf. 

" Condition at first visit. — When the left ear was closed, he could under- 
stand ordinary speech at the distance of five feet, and hear the watch tick 
when in contact with the right ear, the right mastoid process, or the fore- 
head. There was no diminution of sensibility or mobility in the face or 
any part of the body, and his mental faculties were undisturbed. 

" The right membrana tympani was uniformly bluish red, slightly con- 
vex, and greatly dislocated forward. The cone of light was absent, but 
there was a dull, roundish reflex on the posterior lower part. The malleus 
was seen in its ordinary direction from above forward to below downward, 
but its tip lay less deep in the canal than the short process. Neither the 

1 By Dr. Robertson, of Albany, in the Transactions of the American Otological 
Society for 1870. 

2 In the Archives of Otology, Vol. VIII. , No. 4, December, 1879. 



DISEASES OF THE EAR. 383 

drum-head nor the adjacent parts of the ear-canal showed increased sensi- 
bility to the touch, and the drum-head yielded to the probe as if a soft sub- 
stance, harder than liquid, were behind it. 

"When, the next day, I found the condition of the patient unchanged, 
I made an incision with a paracentesis-needle into the drum-membrane, in 
front of and below the handle. The edges of the wound at once retracted, 
and through the gaping opening I saw a reddish, fleshy growth, filling the 
whole space behind the displaced membrana tympani. The cut surface 
showed that the membrana tympani was not thickened. The incision 
caused no particular pain, liberated no pus, serum, or blood, but gave rise 
to considerable hemorrhage, and did not improve the hearing. When 
touched with a probe the tumor gave the sensation as of a somewhat soft, 
fleshy mass. 

" The incision which I had made in the drum-head was fol- 
lowed for a few days by a scanty sero-purulent discharge. On May 23d 
he came to me again, having had great pain in the ear the previous day 
and night. I found the inner half of the auditory meatus occupied by the 
tumor, and the walls of the outer half red, swollen, and tender to the touch. 
I ordered warm instillations of a weak solution of carbonate of soda. Dur- 
ing the next few days the inflammatory swelling in the outer part of the 
ear-canal and its surroundings was more pronounced. On May 29th the 
pain was relieved. An abscess had formed, and pus escaped upon pressure 
on the tragus. Both Dr. Sands [to whom the patient had been referred 
by Dr. Knapp for the removal of the parotidean tumor] and myself thought 
it advisable to delay the operation until the inflammatory symptoms had 
subsided. When in a few weeks this had occurred, on examination (June 
20th) I found that the aural tumor filled the entire meatus, whereas there 
was no noticeable change in the parotidean tumor. My departure for Eu- 
rope being at hand (June 23d), I advised him to let another aural surgeon 
in my stead take charge of the case, and proposed Dr. A. H. Buck, whom 
he also consulted at once." 

The following note furnished by Dr. Sands to Dr. Knapp gives all the 
facts of importance relating to the parotid tumor : 

"June 26, 1877. — I excised the parotid tumor at the New York Hospi- 
tal. A vertical incision, extending from the level of the meatus down to 
the lower end of the growth, measuring from three and a half to four 
inches in length, was made over the middle of the most prominent part of 
the tumor. It included only the superficial tissue. The remaining tissues 
were cut on a grooved director, and carefully dissected out with the fin- 
gers. The large mass was first removed, and beneath it was found a sort 
of pedicle, which was also removed by careful and delicate dissection. 
The growth proved to be an enchondroma, covered by parotid glandular 
tissue externally, and firmly adherent to the digastric and other deep-seated 
muscles. The operation was difficult and tedious, but no large vessel or 



384 DIAGNOSIS AND TREATMENT OF 

nerves were divided. After the operation no paralysis of the facial nerve 
could be detected, although the tumor was apparently situated beneath the 
parotid gland, the tissue of which was freely divided. No connection ex- 
isted between the parotid and aural tumors ; and with Dr. Buck's assist- 
ance I removed as much as I could of the latter by means of a dressing- 
forceps, having previously snapped two pieces of wire in attempting to ef- 
fect removal with the " snare." 

"July 24th. — Patient remained in the hospital until a fortnight since, 
when he went to Ithaca. To-day he returned nearly well." 

At this point my own records take up the history of the case, and from 
them I have compiled the following brief account : 

The external tumor, removed by Dr. Sands, proved to be a mixed 
growth (fibrous chiefly, but in parts cartilaginous, and in still others cellu- 
lar). The parotid gland was found spread out over the mass in the form 
of a capsule, but was not involved in its growth. Very careful search was 
made, but at no point could any offshoot be discovered which might be 
looked upon as the connecting link between the outer tumor and that with- 
in the ear. One portion of the growth seemed to terminate at the tip of 
the stylo-mastoid process. This suggested the idea that the extension of 
the growth to the middle ear had perhaps taken place by way of the stylo- 
mastoid foramen. This could scarcely have been the case, however, as there 
was complete absence of facial paralysis. 

July 25, 1877. — The external wound in the neck has almost entirely 
healed, and the patient is now exceedingly anxious to have an effort made 
to remove the aural growth. The pain in the region of the ear continues, 
and the tumor has increased quite perceptibly in size. By means of a 
curved blunt-pointed knife, made expressly for this case, I was able to cut 
off quite a large portion of the growth. The bleeding was active, but not 
profuse. The patient experienced pain during the cutting operation. As 
soon as the bleeding had ceased, I attempted to further diminish the size 
of the mass by gnawing away small portions with a miniature "rongeur." 
After one or two seizures I was obliged to desist, as the blood poured from 
the ear in a continuous stream, and the bleeding showed no tendency to 
stop of itself. The hemorrhage was readily arrested by stuffing the ear 
with cotton, and applying pressure by means of a bandage passed over the 
head and under the jaw. 

The slippery character of the masses removed (like boiled sago) was a 
very noticeable feature ; and when broken down, the fragments did not 
show the slightest evidence of possessing any fibrous tissue in their com- 
position. 

The microscopic condition of one of these masses, from thin sections made 
by Dr. W. H. Porter, of New York, stained with carmine, and mounted in 
Dammar varnish, was as follows : with low powers it appears that the tumor 
is composed in part of round, oblong, and branching alveoli filled with 



DISEASES OF THE EAR. 385 

medium-sized cells which have imbibed the staining material quite uni- 
formly and abundantly. Only here and there among these cells can the 
outlines of a still more deeply stained nucleus be distinguished. The in- 
teralveolar tissue occupies fully one-half of the entire specimen. It has 
apparently not imbibed any of the staining material, though the round and 
oat-shaped nucleus-like bodies, scattered quite uniformly throughout its 
substance, are as deeply stained as the epithelioid elements in the alveoli. 
At many spots the stained nuclei seem to be surrounded by a perfectly 
colorless hyaline substance, sharply limited against the contiguous inter- 
alveolar tissue : in other words, cartilage cells seem to enter largely into 
the composition of the matrix of the tumor. All the blood-vessels encoun- 
tered are of comparatively large size, and filled with blood-corpuscles. At 
no point can I find distinctly fibrillated connective tissue. 

Later, on the day of the operation, a second and very unsatisfactory 
effort was made to diminish the size of the growth. The copiousness of 
the bleeding, however, again obliged me to desist. 

July 26th. — I introduced four red-hot needles in succession into the 
mass, with a view of diminishing the bleeding. As soon as the rongeur 
was used, however, the bleeding became as active as on previous occasions. 
Before I had reached the middle ear in my mining operations, I thought it 
advisable to abstain from further interference. 

Soon afterward a large abscess developed on the side of the neck, just 
below the mastoid process, and the patient was again transferred to Dr. 
Sands' care. 

Early in August the patient returned to his home in the central part of 
this state. Already at that time the growth in the middle ear and meatus 
had begun to extend into the neighboring parts. On the 24th of October, 
however, when he came to New York for a few days, I was surprised to see 
how formidable the growth had become in that short interval of ten weeks. 
The auricle had been dislocated outward a distance of at least an inch 
beyond its normal position. This dislocation seemed to be due to the de- 
velopment of a broad, hemispherical mass of tissue beneath (i.e., on the inner 
side of) the outer ear and on all sides of it. The external meatus was still 
filled with the growth, and there were two fistulous openings, — one in 
front of, the other behind, the auricle, — from which pus and blood could 
readily be forced by pressure made in the neighborhood. The mass could 
be grasped and moved a little as a whole, but in the main its attachments 
were very firm. Dr. Sands, Dr. Knapp, and I, each agreed that an operation 
for the removal of this growth was out of the question. The patient re- 
turned home. 

On the 29th of May, 1878, Dr. S. H. Peck, his medical adviser, wrote to 

me as follows : " The tumor has attained an enormous growth, is larger 

than a child's head, and of nearly the same shape ; it measures thirteen 

inches in circumference at the base, and is partly covered by integument. 

25 



386 DIAGNOSIS AND TREATMENT OP 

His general health is very much impaired and he is greatly emaciated. He 
has slight attacks of hemorrhage. I use carbolic acid as a disinfectant. 
He takes morphine ; does not suffer much pain." 

After the patient's death from exhaustion, on the 15th of September, 
1878, Dr. Peck sent to Dr. Knapp the following memorandum with regard 
to the condition of the tumor at that time : 

"At the time of death the tumor measured in circumference at the base 
twenty-two inches, in the antero-posterior diameter eight inches, in the 
vertical seven inches. Its elevation over the surface of the skull was five 
inches. It extended anteriorly to within half an inch from the orbit, pos- 
teriorly nearly to the occipital protuberance, superiorly to the parietal emi- 
nence, inferiorly to the angle of the lower jaw. The ear, normal in size 
and appearance, rested upon the external surface of the tumor, being carried 
outward by the tumor. In general appearance the tumor presented a lobu- 
lated form, viz. : a superior, middle and inferior lobe, the superior being 
above the ear, the middle behind, and the inferior below the ear. Masti- 
cation was slightly interfered with, simply by the weight of the tumor. No 
protrusion of the growth into the bucco-pharyngeal cavity was noticeable. 
No mental disturbance." 

Subjective and objective systolic murmurs. — Subjective systolic murmurs 
are by no means rare, but those which can be heard by a second person, as 
well by the patient, are, I believe, very rare. I know that I have re- 
peatedly, in cases of subjective pulsating noises, applied the auscultation- 
tube to the affected ear, but only once have I been rewarded by hearing 
what the patient had previously described. In the case to which I re- 
fer, the patient, an intelligent woman, about forty years of age, consulted 
me at the Infirmary for a very distressing puffing noise in the right ear. 
She said that she had discovered that, by making pressure behind the right 
ear, she could stop the noise. Her hearing had not been affected, nor had 
she experienced any pain in the right ear. On examination, I found the 
drum-membrane normal both in texture and in position. No visible pulsa- 
tion could be detected, nor was there any congestion of the parts. By 
means of the auscultation-tube, however, a distinct systolic bruit was heard, 
both by Dr. "Wm. McFarland, who was at that time my assistant, and by 
myself. The pressure of the conical end of the auscultation-tube against 
the walls of the orifice of the auditory canal rendered the bruit inaudible. 
The heart-sounds were normal, and the carotids of the two sides seemed 
to beat with equal force. Unfortunately, I neglected to ascertain whether 
firm pressure upon the carotid of the right side caused the noise to 
cease, or not. From the fact, however, that the woman herself was able to 
stop the noise by pressing upon some spot situated behind the ear, and 
from the fact that the conical hard-rubber end-piece of the auscultation- 
tube accomplished the same result, there can be very little doubt but that 



DISEASES OF THE EAR. 387 

the bruit originated either in some twig of the stylo-mastoid artery, which 
supplies the drum-membrane and posterior portion of the tympanum, or 
in that branch of the posterior auricular artery which supplies the external 
auditory canal. It does not seem to me to be necessary to assume that the 
noise in question owed its origin to an aneurismal dilatation : it might 
equally well have been caused by some pathological process that took place 
outside of the artery, as, for example, by the contraction of cicatricial tissue, 
in its neighborhood, causing diminution in its calibre. 1 

Otalgia. — In the great majority of instances pain in the ear implies in- 
flammatory action either in the middle ear or in the external auditory canal. 
In the absence, however, of any evidence of inflammation in these parts, we 
are compelled to seek for the cause in some adjacent or more remote or- 
gan. It is to this class of cases that the term "reflex or sympathetic otal- 
gia " is usually applied. According to my experience, such cases are by no 
means so common as some authorities would have us believe. When a 
patient complains of pain in the ear, and, on examination, I fail to find any 
adequate cause for its existence in the condition of either the external or 
the middle ear, I at once suspect his teeth of being at the root of the trou- 
ble ; and in the majority of these cases of otalgia I find sufficient dental 
disease to justify the belief that this condition is the fundamental one, and 
the otalgia simply a reflex phenomenon. If the teeth are found to be in a 
healthy condition, we may think next of a malarial, rheumatic, or syphilitic 
origin for this neuralgia of the ear. I have seen cases in which I have been 
disposed to ascribe the otalgia to malarial, rheumatic, or syphilitic influ- 
ences, but I have never yet encountered a case in which I was justified in 
entertaining more than a mere suspicion. In one of these cases the pain 
was clearly due to a chronic arthritis of the temporo-maxillary joint ; the 
motions of the jaw causing a plainly audible creaking sound. In another 
case the otalgia finally terminated in a facial paralysis on the same side of 
the face. The suspicion that the affection was s^hilitic in its nature was 
strong, but as the patient did not remain long under observation, I was un- 
able to arrive at a satisfactory diagnosis. 2 

I have had absolutely no experience with affections of the chorda tympani 
nerve, and will therefore omit all mention of it here. 

1 Consult, on this subject, a paper by Dr. J. Orne Green, of Boston, in the Trans. 
of the American Otol. Society for 1878. Dr. Spencer, of St. Louis, has also, I believe, 
written on this subject in a recent number of one of the St. Louis journals. 

2 Consult, on this subject, a paper by J. Ome Green, on Neuralgia in and about the 
Ear, Transactions American Otological Society, 1874 ; another by Voltolini, on Otal- 
gia Intermittens, in the Monats. f. Ohr., May, 1878, and July, 1878 ; a third by Gruber, 
on Otalgia, in the M. f . O., September, 1869 ; and, finally, a fourth by Weber-Liel, on 
Neuralgia of the Ear, in the M. f. O., May, 1878. 



CHAPTER XL 

DIFFERENT FOEMS OF AURAL DISEASE IN WHICH THE LABY- 
RINTH IS BELIEVED TO BE INVOLVED. 

This chapter comprises a series of aural disturbances, all more or less 
grave in character, and many of them very obscure in their pathology. It 
is customary to group them together under the heading, "Diseases of the 
Labyrinth," but, unfortunately, there are good reasons for believing that 
this convenient designation cannot rightfully be applied to more than a fair 
proportion of the entire number. In the cases of total deafness following 
the disease known as epidemic cerebro-spinal meningitis, there can be very 
little doubt that the chief lesions are located in the labyrinth. 1 I will give 
in brief outlines, the histories of two such cases. In the first one of these 
the patient, a boy seven years of age, was brought to the Infirmary on the 
26th of June, 1872. His father stated that ten weeks previously his son 
had been taken ill with severe headache, fever, pain in the back, and bend- 
ing backward of the head and shoulders. About the fourth day of the at- 
tack, it was noticed that the boy was decidedly deaf, and twenty-four hours 

1 And yet, even in these cases, the lesions found after death are sometimes confined 
almost entirely to the middle ear. Thus, for example, Moos (Archives of Ophthalmol- 
ogy and Otology, Vol. III. , No. 2, p. 177) reports a case of cerebro-spinal meningitis, 
in which decided, if not total deafness was observed two days before death. At the 
autopsy, it was found that the tympanic mucous membrane, on both sides, was de- 
cidedly hypersemic and swollen. There were also very decided evidences of a general 
meningitis. But the auditory nerve, in the porus acusticus internus, was quite free 
from evidences of inflammation, on both sides. Both labyrinths were also examined 
and found normal in every respect. 

Klebs also (Virchow's Archiv, Vol. 34, p. 353 et seq.) narrates the history of a some- 
what similar case of meningitis. The patient, a subordinate officer in the army, was 
taken ill on the 10th of April, and died on the 7th of May. No deafness was noticed 
when he was first taken ill. Soon afterward, however, he gradually became totally 
deaf. At the post-mortem examination the auditory nerves (examined microscopically) 
were found to be perfectly normal. The terminal apparatus of the cochlea was also 
found to be normal. The middle ear, however, was found (on both sides) to be the 
seat of extensive inflammatory changes. Strong bands of connective tissue, well sup- 
plied with blood-vessels, traversed the cavity in all directions, and must of necessity 
have greatly impeded the movements of the ossicles, to which they were adherent at 
numerous points. 



DISEASES OF THE EAR. 389 

later lie appeared to have lost the sense of hearing entirely. There had 
been no discharge from either ear, and the only complaint which the boy 
had made with reference to his ears was, that he constantly heard noises in 
them of the most varied character. This symptom still persisted at the 
time when I saw him. During convalescence, whenever the patient at- 
tempted to walk without assistance, he experienced great difficulty in main- 
taining his equilibrium. Although this difficulty had afterward greatly 
diminished, it was still sufficiently marked, when the boy came to the In- 
firmary, to attract my attention. On examination, I found both external 
and middle ears in a comparatively healthy state. The deafness was abso- 
lute. 

In the second case, the patient, a boy four years of age, and in appar- 
ently good health, was brought by his mother to the Infirmary on the 24th 
of September, 1872. She gave the following history : 

Five months previously the boy had been taken with symptoms of cere- 
bro-spinal meningitis, viz., vomiting, pain in the head, delirium, high fever, 
and opisthotonos. In the course of a week the delirium passed off, and 
then the parents noticed that the child was entirely deaf. Since recovery 
the child had shown an "ugliness" of disposition to his family which they 
had never noticed before, and a desire to destroy clothing and other arti- 
cles which came within his reach. His gait had been staggering and was 
still, at the time when I saw him, somewhat unsteady. Deafness complete. 
Right membrana tympani opaque and sunken ; left, in nearly the same con- 
dition. In other respects the middle ears appeared to be normal. 

In both of these cases it is reasonably clear that the original disease 
partook of the nature of a meningitis, and that the inflammation at a cer- 
tain stage spread to both labyrinths. If the inflammation had not involved 
the labyrinths, but had simply damaged the main trunks of the auditory 
nerves, it is difficult to understand why the trunks of the facials, which are 
so intimately related to these nerves, should have escaped. Equally great 
are the difficulties that stand in the way of the assumption that the auditory 
centres in the medulla oblongata are the parts involved. Weber-Liel has 
shown, 1 by direct experimentation, that a free communication exists between 
the endolymphatic and perilymphatic spaces of the labyrinth and the 
extralabyrinthine intracranial spaces, and it is probably by this route that 
the inflammation spreads from the meninges to the labyrinth. 

Epidemic cerebro-spinal meningitis is not the only epidemic affection 
which is apt to be followed by labyrinthine disease. Scarlet fever, typhoid 
fever, and measles, also furnish a large proportion of the cases of this form 
of aural disease. In one instance that came under my observation the sud- 

1 Virchow's Archiv, Bd. 77, 1879. 



390 DIAGNOSIS AND TREATMENT OF 

den and complete loss of the hearing-power took place shortly after an 
attack of mumps. In another case the mother attributed the loss of hear- 
ing to a series of epileptic seizures. As the child, however, had been sub- 
ject to otorrhcea, it is quite probable that the relations were reversed, viz., 
that the epileptic attacks were due to the aural affection. In many of these 
cases the deafness develops at a time when there is no reason to believe 
that even a trace of meningitis exists, and we must, therefore, in such 
cases, seek for some other mode of origin. The high degree of inflamma- 
tion of the middle ear which characterizes a certain proportion of these 
cases suggests the likelihood of an extension of the inflammation from the 
tympanum to the labyrinth. 1 Blood-vessels pass freely from the tympanum 
to the vestibule through the stapedio-vestibular ligament, and, if I am not 
mistaken, also through the membrana tympani secundaria. There are, 
therefore, no anatomical reasons why such an extension of the inflammation 
should not take place. As a matter of fact, however, an acute inflamma- 
tion of the middle ear, no matter how severe, rarely leads (during the acute 
stage) to serious and permanent impairment of the hearing, or, in other 
words, to serious disease of the labyrinth. This is the only objection that 
I know of, to the view that in some of these cases of total loss of hearing 
the damage may be due to an extension of the inflammation from the mid- 
dle ear to the labyrinth. I might frame still other hypotheses for the pur- 
pose of explaining these obscure cases of rapid loss of hearing, but the 
actual facts in our possession are so few that I prefer to abstain from any 
further theorizing on the subject. 

In a few cases the loss of the power of hearing takes place in a gradual 
manner, and without any attendant symptoms that might throw light on 
the cause of such loss. As an example of this, I might mention the follow- 
ing case : A healthy young girl, thirteen years old, was brought by her 
mother to the Infirmary on the 3d of November, 1873. Six months pre- 
viously the mother had noticed that her daughter was a little deaf, and in 
the course of about two weeks the child completely lost the sense of hear- 

1 In this connection I might mention a case of intermittent complete deafness, in a 
boy about four years old. The child, as I learned from the mother, had twice before 
remained in a condition of total deafness for a period, each time, of several weeks. 
During the intervals he had heard sufficiently well for those around him to be able to 
make themselves understood. At the time when I saw the boy, he had been absolutely 
deaf for a period of six weeks, and the parents were beginning to fear that he had 
permanently lost the sense of hearing. On examination I found the drum -membranes 
so highly atrophied that each of them lay like a thin film in contact with the purplish 
and swollen mucous membrane of the inner wall of the tympanum. The tonsils were 
enormously swollen, and the naso-pharyngeal space seemed to be almost obliterated by 
the highly swollen condition of the surrounding walls. As a consequence the boy was 
■^obliged to breathe wholly through the mouth. So far as I could ascertain by actual 
experiment, the boy was totally deaf. (The subsequent history of this case is un- 
known to me. ) 



DISEASES OF THE EAR. 391 

ing. No illness of any kind preceded or accompanied this loss, and even 
the dizziness and staggering gait, which are so often associated with the 
sudden development of deafness, were absent in this case. An examina- 
tion showed that the middle and external ears were in every respect 
normal. 

In this category may be placed those cases of total loss of the power of 
hearing which are observed in women shortly after confinement. 

Voltolini * maintains that there is such a thing as a primary acute in- 
flammation of the labyrinth, and gives the histories of a few such cases. 
He admits that this form of disease is often mistaken for " inflammation of 
the brain," and I suspect that the error — if error it be — is one that can 
scarcely be avoided. In some instances, however, the history of the prog- 
ress of the disease shows quite clearly that the meningitis does not pre- 
cede the disease of the labyrinth. Thus, for example, Schwartze has pub- 
lished 2 the details of a case in which the symptoms during life pointed to 
an acute primary inflammation of the labyrinth. Subsequently meningitis 
developed and the patient died. At the autopsy no other cause for the 
general meningitis was found beyond a purulent inflammation of the laby- 
rinth. 

The term "Meniere's disease " is loosely applied to all those cases of 
sudden loss of hearing (on one or on both sides, complete or incomplete) 
which are associated with vertigo, tinnitus, nausea, inability to maintain 
one's balance, etc. In some of these cases, especially in young individuals, 
it is more than likely that the disease should be considered as a mild attack 
of epidemic meningitis, with an extension of the inflammation to the laby- 
rinths. In 1872 this disease was fairly epidemic in this city and vicinity, 
and in parts of Connecticut, and many of the patients were brought to the 
Infirmary in the hojje that their deafness could be relieved. In a few of 
these cases the cerebral disturbances seemed to have been very trivial, and 
had it not been for the fact that the disease was epidemic and that I was 
interested in learning something about it, I think I might very easily have 
overlooked the primary disease and have considered some of these cases, 
at least, as instances of a primary affection of the labyrinth. Taks as an 
example the following case : 

The patient, a girl, about fourteen years of age, was brought to the In- 
firmary on the 8th of May, 1872. From her mother I learned that three 
months previously she had been taken ill one day with dizziness, noises in 
the ears, slight disturbance in vision, photophobia, and finally vomiting. 
On the afternoon of the second day the mother noticed that she was very 
deaf, and by bed-time it had increased to such an extent that they were 

1 Monatsschrif t fur Ohrenheilkunde, October, 1867 ; June, 1868. See also a case 
reported by Schwartze, in the Archiv fiir Ohrenheilkunde, XIII., p. 107. 

2 Archiv fur Ohrenheilkunde, Bd. XIII., p. 107. 



392 DIAGNOSIS AND TREATMENT OF 

obliged to communicate with her by writing. So far as I could learn there 
had been no delirium, no opisthotonos, nor any other decided symptom of 
meningitis. Although the other symptoms soon disappeared, the deafness 
and the inability to easily maintain her equilibrium persisted. The latter 
symptom had not entirely disappeared at the time when I saw the patient, 
but the deafness was apparently as profound as on the second day of the 
attack. I found the middle ears practically normal. 

In other cases it is extremely difficult to picture to ourselves the precise 
nature of the pathological processes and the exact locality in which they are 
taking place. When we take into consideration the apoplectiform char- 
acter of the attack or attacks, — for there are often several of them, — the 
nearness of the auditory centre to other important centres (that governing 
the pneumogastric, for instance), and the fact that, when the inflammation 
spreads from the tympanum to the labyrinth, all those concomitant symp- 
toms which are considered as essential features of the typical Meniere's dis- 
ease, — viz., the dizziness, the staggering gait (or movements in a circle), 
and the nausea or vomiting, — are lacking; when we consider all these 
things, I say, it is hard to resist the belief that the medulla oblongata is 
more likely to be the seat of the disease than the labyrinth. 1 

1 In this connection I might mention the results of experiments made by Arthur 
Boettcher, in 1872, on pigeons, and published in the Archiv f ur Ohrenheilkunde for 
1874. Those made by Flourens, many years earlier, seemed to determine beyond a 
doubt that in that part of the labyrinth which is represented by the semicircular ca- 
nals resides the power of controlling the equilibrium of the body. In 1870 Goltz re- 
peated these experiments, and was led to the conclusion that the semicircular canals 
' ' were organs of sense for the maintenance of the equilibrium of the head, and so also, 
indirectly, of the entire body." Boettcher, by operating in a somewhat different man- 
ner from that pursued by his predecessors, was able to divide the posterior vertical 
semicircular canal of the frog without producing in that animal any of the peculiar 
movements described by Flourens. This induced him to carry out a series of similar 
experiments upon pigeons, the results of which may be stated as f ollows : 

In those cases in which the operation was carried out without any special precau- 
tions, and in which, as a consequence, there was considerable hemorrhage from the 
vessels in the neighborhood of the semicircular canals, the results obtained were essen- 
tially the same as those described by Flourens, Goltz, and others, viz., twisting of the 
head to one side, rolling movements, travelling in a circle toward the affected side 
( u mouvements de manege''' 1 ), unsteady and uncertain gait, pendulum-like motions of 
the head, etc. In one case the twisting of the head and the rolling movements did 
not appear until the fifth day after the second operation (division of the canal on the 
opposite side). At the post-mortem examination in this case the evidences were found 
of an acute inflammation of the dura mater in the vicinity of the region where the 
second operation had been performed, and extending thence to the portion which cov- 
ers the cerebellar hemispheres. 

In a second series of cases, although great care was used in performing the opera- 
tion, the results varied very greatly. Thus, in one case, after division of the inner ver- 
tical canal of one side, the bird showed a tendency to fall forward, but this continued 



DISEASES OF THE EAR. 393 

I will give here a few examples of that form of Meniere's disease in which 
the apoplectiform character of the attack would lead a careful observer to 
doubt seriously the correctness of the prevailing view that the labyrinth in 
such cases is the region chiefly or exclusively affected. 

for only two days. After division of the horizontal canal of the opposite side, pendu- 
lum-like movements of the head began, and the bird showed a tendency to fall toward 
that side. The pendulum-like movements, however, soon ceased, and the bird slowly 
recovered the use of its legs. The power of flight was totally lost after the second 
operation. 

In another case, after division of the semicircular canals, the tendency to move in a 
circle showed itself, but soon passed off. Although a semicircular canal on each side had 
been divided, no pendulum -like movements occurred. A short time after the operation, 
and notwithstanding the fact that the continuity of the semicircular canals was broken 
on both sides, no disturbance of the equilibrium could be noticed. Furthermore, the 
tendency to move in a circle scarcely showed itself at all when the bird walked, while 
during its flight it was very marked. The peculiar manner of holding the head side- 
ways, and the attacks of bringing the head down in such a way that the top would 
touch the floor, did not appear as the immediate result of the operation, but for the 
first time as late as four weeks after the operation, that is, after the full disappearance 
of all the immediate effects of the operation. These peculiar symptoms were therefore 
due to some disturbances which must have developed at a later date, and were only 
indirectly connected with the division of the semicircular canals. The rolling move- 
ments appeared in connection with the twisting of the head whenever the bird was 
very greatly disturbed. There was no appreciable connection between the rolling 
movements and the tendency to move in a circle. The latter symptom was noticeable 
for a long time before the rolling movements appeared, and when these came, the ten- 
dency to move in a circle disappeared altogether. 

In still another case, after the division of both outer vertical semicircular canals, 
the twisting of the head and the rolling movements did not appear until after a lapse 
of about three weeks. There was total loss of the power of flight, and the left leg ap- 
peared to be permanently affected. At the autopsy, an extravasation of blood was 
found in the pia mater, on the left side, just over the origin of the acoustic nerve. 
The supposition is therefore justifiable that the symptoms which developed later, — the 
twisting of the head and the rolling movements, — were due to this extravasation. 

Finally, in a fourth case, after the division of the lower arms of both vertical semi- 
circular canals, the bird was still able to hold its head in a perfectly normal position. 
The ability to walk and the power of flight were very materially diminished ; yet they 
improved very decidedly in the course of a short time. About ten days after the oper- 
ation, well-marked pendulum-like movements in a vertical direction set in, and the 
power of flight appeared to be quite destroyed. At last these symptoms, too, almost 
entirely disappeared. No lesions found in the brain or its membranes at the autopsy. 

In a third series of cases the operation was performed more successfully, as regards 
the avoidance of injury to neighboring important parts ; and in these cases, after the 
division of one or more semicircular canals on both sides, but very slight and transient 
motor disturbances followed; the birds in a very short time entirely recovered their 
powers of locomotion, of maintaining perfectly their equilibrium, and of picking up 
particles of food. 

By these very important experiments Boettcher proves that the semicircular canals 
may be divided loithout causing any of the symptoms described by Flourens and Goltz 
as specially due to a lesion of this apparatus. If, as he says, the destruction of the 



394 DIAGNOSIS AND TREATMENT OF 

Case I. — The patient, a decidedly stout, full-blooded lady, about forty 
years of age, consulted me on the 1st of August, 1871. She stated that 
on the previous Christmas morning, while in the enjoyment of her usual 
good health, she had been suddenly seized with a severe pain in her head, 

semicircular canals were the cause of these characteristic motor disturbances, the latter 
should have persisted as a permanent thing ; instead of this, however, they soon dis- 
appeared entirely, notwithstanding the fact that the apparatus of the semicircular can- 
als had been practically destroyed. Another point to which he calls attention, and 
which certainly has a suspicious character about it, is this : the motor disturbances, 
when only one side is operated upon, always appear in the extremities of the side upon 
ichich the operation has been performed. Thus, the movements in a circle are always 
executed toward the injured side. A slight paresis of the foot or wing of one side 
would be sufficient to cause these peculiar movements in a circle, which have hitherto 
been considered as something almost specific of a lesion of the semicircular canals. 

In conclusion, Boettcher thus states his views regarding this question : ' ( These 
disturbances of equilibrium manifest themselves either immediately after the opera- 
tion, — and are then due to an injury of the brain, — or after tie lapse of a few days, in 
which case they are due to pathological processes which have involved the central 
portions of the nervous system." 

As regards an injury to the brain, Boettcher calls attention to the fact that the au- 
ditory nerve is not bound down at any point between its origin in the brain, on the one 
hand, and the fundus of the meatus auditorius internus, on the other ; and that con- 
sequently any operative interference with the semicircular canals, which may result in 
pulling upon or tearing the ampullae or sacculi, — that is, in pulling upon the vestibular 
fibres of the auditory nerve, — must necessarily produce a certain amount of injury in 
that portion of the brain from which these fibres come. The variable results obtained 
from interference of this kind are due to the circumstance that at one time one set of 
fibres is pulled upon, while at another, another set. In this connection he quotes 
Brown- Sequard as saying : "I have ascertained that the phenomena observed in these 
experiments do not depend on the section of these canals, as this operation may not 
cause these phenomena, but that they are the results of an irritation of the auditory 
nerve, from the drawing upon it by the membranous semicircular canals at the time 
we divide them." (Course of Lectures on the Physiology and Pathology of the Central 
Nervous System, Philadelphia, 1864, p. 195.) 

In answer to the objection of some, that the motor disturbances here under consid- 
eration are of too long duration for so slight a lesion, and always take place on the 
side of the body corresponding to the lesion, — which does not agree with the generally 
accepted notion that an injury to one side of the brain should be followed by disturb- 
ances upon the opposite side of the body,— Boettcher again cites the following remarks 
of Brown- Sequard (loc. cit.) : " It is a fact worthy of attention, that a puncture with 
a needle through the anterior pyramids, which contain very nearly all, if not all, the 
nerve-fibres employed in voluntary movements, will hardly produce a momentary con- 
traction in some muscles ; while certain punctures through the olivary column of the 
medulla oblongata at once produce a spasm of many muscles, although this column 
does not contain more than very few (if any at all) voluntary motor fibres ! And now, 
to add to the strangeness of the fact, in this last case the muscles remain contracted 
sometimes for hours, sometimes for days and weeks." 

"... There is. therefore, in some parts of the nervous centres, a property of act- 
ing in a persistent manner to produce muscular spasms during and after a mechanical 
excitation." 



DISEASES OF THE EAE. 395 

accompanied by dizziness, nausea, and loud noises in both ears. She was 
walking about the room at the time of the attack, and was obliged to take 
hold of some article of furniture, in order to escape from falling. The ob- 
jects in the room seemed to her to be turned upside down ; she also saw 
double. She lay down upon the bed, and soon afterward vomited. When 
her friends came into the room and spoke to her, she discovered that she 
had completely lost the sense of hearing. The nausea and vomiting ceased 
in the course of a few hours, and, with the disappearance of these symptoms, 
she experienced decided relief from the pain in the head. Her hearing 
soon began to return, and at the end of about six days she was able to hear 
fairly well. The double vision lasted somewhat longer, and did not finally 
disappear until after the lapse of several weeks. The subjective noises, how- 
ever, and a moderate degree of deafness had continued to annoy her up to 
the time when I saw her. I tested the hearing and found it to be : E., -f ^| ; 
L., -°y°2 3 -. The sound of the vibrating tuning-fork, no matter at what point 
it was placed on the cranium, was heard best in the right ear. Aside from 
a slightly opaque condition of the drum-membranes, the external and mid- 
dle ears appeared to be normal. Both pupils responded to the light, but 
the left was fully twice as large as the right. From Dr. Carl Keincke I 
ascertained that the ophthalmoscopic examination had yielded only nega- 
tive results. Auscultation revealed the existence of a loud systolic bellows- 
murmur, heard most distinctly at the base of the heart. (The patient was 
not seen again.) 

Case II. — The patient, a well-to-do farmer, about sixty years of age, con- 
sulted me on the 15th of April, 1873. He gave the following history : 
About two months previously he was taken suddenly ill with severe pain in 
the head, dizziness, and nausea. The objects in the room seemed to be 
revolving in a circle. He lay down, and in about five minutes all the more 
marked symptoms, with the exception of the headache, disappeared. The 
attack, however, left him in such a prostrated condition that he was com- 
pelled to keep his bed for about three weeks. During this period he occa- 
sionally vomited his food, and whenever he attempted to walk about the 
room he experienced great difficulty in maintaining his equilibrium. About 

"... The parts of the base of the encephalon which are capable of producing 
persistent spasms seem to be quite different from those employed in the transmission 
of sensitive impressions, or of the orders of the will to muscles, at least in the medulla 
oblongata and the pons Varolii. They constitute a very large portion of these two or- 
gans, and perhaps the three-fourths of the first one ; they are placed chiefly in the lat- 
eral and posterior columns of these organs ; many of their fibres do not decussate, and 
produce, therefore, spasms on the corresponding side of the body. " 

This is important evidence in favor of Boettcher's view : showing, as it does, that 
a slight injury of the medulla oblongata, — the very part of the brain from which the 
anditory nerve springs, — may result in motor disturbances on the corresponding side 
of the body, and, furthermore, that these disturbances may last for quite a long- time.. 



396 DIAGNOSIS AND TREATMENT OF 

five weeks after this attack lie experienced two more of a similar character, 
the interval between the two not exceeding twenty-four hours. At the 
time when he consulted me there was complete deafness in the right ear, 
the sound of the tuning-fork being referred very promptly by the patient 
to the right ear. I was unable, however, to ascertain satisfactorily at what 
precise time during the previous eight weeks this loss of the hearing-power 
had taken place. The patient complained chiefly of a throbbing pain 
throughout the left side of the head. The noises in the left ear also dis- 
tressed him. On examination I found both ears in a comparatively healthy 
state. Suction with Siegle's tympanoscope diminished the throbbing ap- 
preciably. An examination of the urine showed simply a rather low speci- 
fic gravity (1004). 

Dr. Brown-Sequard, to whom I referred the patient, wrote as follows : 
" Your patient is evidently attacked with what has been miscalled Meniere's 
disease (an affection which I had described in lectures and books three or 
four years before Meniere spoke of it). He has no organic affection of the 
brain so far as it is possible to say so from the fact that there are no brain- 
symptoms actually. I would, however, recommend the use of the two 
medicines for which I have given him a prescription, and I will suggest 
that counter-irritation of some kind be used behind each of the ears. The 
patient must live well, taking chiefly nourishing food, but avoiding excess 
as regards quantity of any kind of food. He has no need of stimulants." 
The prescription referred to is the following : 

I£ . Sodii iodidi : 3 ijss. 

Sodse bicarb 3 j. 

Infus. calumbse fl. § ij. 

Tine, rhei 3 ij- 

M. S. — A teaspoonful and a half three times day before meals, with a 
little water. (B.-S.) 

Also: 

IJ . Strychnise sulphatis gr. j. 

Acid, sulph. dil , n\ xv. 

Aquae destillatse fl. § v. 

M. S. — Two teaspoonfuls three times a day after meals. (B.-S.) 

The plan of treatment suggested above was carried out faithfully up to the 
23d of May. As the effects of the strychnine were then beginning to show 
themselves (muscular pains and stiffness), the patient was advised to discon- 
tinue internal treatment. His general condition had certainly improved 
during the interval, but the aural symptoms had remained unchanged. 

Case HI.— The patient, a healthy but rather full-blooded lady, about 
thirty years of age, consulted me on the 17th of September, 1872. She 



DISEASES OE THE EAK. 397 

stated that during the previous spring she had experienced a sudden at- 
tack of severe pain in the head, with loud noises in the right ear. After- 
ward she discovered that she could not walk without staggering, and that 
the hearing of the right ear was very much impaired. The former symp- 
tom had gradually disappeared, but the deafness and the noises still per- 
sisted. On examination, I found both drum-membranes — so far as they 
could be seen — normal in appearance. In each external auditory canal, 
however, there was a hemispherical exostosis, sufficiently large to conceal 
the lower two-thirds of the membrana tympani. These symmetrically 
placed bony tumors were in close proximity to the drum-membranes. The 
tuning-fork was heard best in the left ear ; the ticking of the watch was 
not heard at all in the right ear ; when the left ear was closed, words 
spoken in an ordinary tone of voice were not heard correctly in the right 
ear beyond a distance of about one foot. 

In the course of about two morths, under the employment of the iodide 
of potassium in ten- grain doses, repeated three times a day, the patient so 
far regained her hearing that she could distinguish the ticking of my watch 
at a distance of half an inch, and words spoken in an ordinary tone of voice 
at a distance of about five feet. The tinnitus continued unchanged. Two 
or three times, during this period of eight weeks, the remedy had disagreed 
with her, and she had been obliged to discontinue it for about one week 
each time. 

As recently as during the summer of 1879, I learned that the patient 
had not experienced a relapse. 

Case IV. — The patient, a clerk, about forty years of age, and a decided 
sufferer from stomach indigestion (nausea, heartburn, gaseous eructations, 
etc.), was taken suddenly ill, about the 15th of August, 1880, with marked 
dizziness and noises in the left ear. When he attempted to walk, he found 
that he could do so only with great difficulty, as he was unable to keep his 
balance. On the second or third day he discovered that his sense of hear- 
ing in the left ear was not as acute as before the attack. 

On the 30th of August he consulted his regular medical adviser, and 
was by him sent to me for a report on the condition of his ear. Although 
his gait had, he thought, steadily improved, it was still at that time notice- 
ably unsteady. He not only used a cane, but in walking out of doors he 
seemed to avail himself of the assistance of his wife. He was barely able 
to distinguish the ticking of my watch, when I pressed it firmly against the 
left mastoid process. With the right ear closed, he distinguished words 
spoken in an ordinary tone of voice at a distance of several feet from the 
left ear. The tuning-fork was heard best (by bony conduction) in the right 
ear. The drum-membrane showed slight evidences of a subacute catarrhal 
inflammation, and there was also a moderate degree of naso-pharyngeal 
catarrh. 



398 



DIAGNOSIS AND TREATMENT OF 



With regard to the cases in which the auditory nerve, either before or 
after its entrance into the labyrinth, is the part believed to be principally 
affected by constitutional syphilis, I find that my material is far too 
scanty and too imperfect to justify any special conclusions. In these cases 
it is generally assumed that the labyrinth is the seat of the syphilitic lesion. 
It is quite possible, however, that the lesion may be in the middle ear, or 
in the auditory nerve before it enters the labyrinth. It is a peculiarity of 
poisoning by syphilis that almost any spot in the body may become the 
seat of well-marked textural changes, such as increased vascularity, infiltra- 
tion, proliferation, or death. The parts in the immediate neighborhood 
may exhibit no evidences whatever of participation in the process. Thus, 
for example, the mucous membrane lining the niche for the round window, 
or the membrana tympani secundaria itself, may become congested and 
very much swollen, without narrowing of the Eustachian tube, without exu- 
dation of fluid into the middle ear, and without the slightest change in the 
condition of the drum-membrane — or, in other words, without any dis- 
coverable evidence of disease in the middle ear. The swelling of these 
parts, and especially of the secondary tympanic membrane, cannot take 
place without producing pressure upon the fluid of the labyrinth. This 
lesion, therefore, would be competent to produce the hardness of hearing, 
the staggering gait, and the dizziness observed in some of these cases. 1 If 
not arrested by treatment, the swelling might increase to such a degree 
that the displacement outward of the foot-plate of the stirrup would no 
longer compensate for the pressure exerted at the round window upon the 
contents of the labyrinth. In that event we should have not only a me- 
chanical interference with the working of the cochlear apparatus, but also 
an intralabyrinthine anaemia (due to pressure), which would very soon cause 
disturbances in the nutrition of the delicate structures of the cochlea. All 
degrees of hardness of hearing might in this way be produced. 

Lesions at the oval window, by obstructing the action of the stirrup, 
would likewise be competent to diminish very materially the power of hear- 
ing. Thus, even complete anchylosis of the stapedio-vestibular articula- 
tion, might result from syphilitic disease. 

Finally, still another possibility must be taken into consideration. The 
auditory nerve, after its separation from the facial in the meatus auditorius 



1 The fact that pressure upon the fluid contents of the labyrinth may cause dizzi- 
ness, nausea, and perhaps even a staggering gait, does not appear to me to add strength 
to the view that in some part of the labyrinthine cavities — e.g. , in the semicircular 
canals — resides the organ which co-ordinates the movements of the body, or the organ 
of equilibrial sense. It seems to me to show simply this, that pressure has been made 
upon filaments of the sympathetic nerve. Pressure upon the mucous membrane of the 
mastoid antrum (see Case I. on p. 303) may produce precisely the same train of symp- 
toms, and yet nobody has ever ventured to suggest that the organ for controlling the 
movements of the body is situated in that cavity. 



DISEASES OF THE EAR. 399 

interims, passes through the minute openings in the cul-de-sac of the mea- 
tus and enters into numerous bony channels in the modiolus. The most 
insignificant pathological changes in these minute channels- — changes which 
it might be difficult to detect even with the microscope — would suffice to 
inhibit the functional capacity of the bundles of auditory nerve filaments 
contained within them. 

In the present state of our knowledge of aural pathology, therefore, we 
can only use the expression " syphilitic disease of the labyrinth " in a some- 
what loose sense, and as a term of provisional usefulness. 

I will give here, in brief outlines, the histories of some of my cases 
which belong clearly in the category which we are now considering : 

Case I. — The patient, a man twenty-nine years of age and in good gene- 
ral health, consulted me on the 24th of March, 1877, at the request of Dr. 
Hoosa. During January of that year he had suddenly and almost com- 
pletely lost the hearing-power in both ears ; chancre eighteen months 
previously. No other evidence of syphilis, with the exception of an ill-de- 
fined ulcer on the right side of the tongue, near its tip. Nothing worthy 
of note in the condition of the middle ears. Antisyphilitic treatment (by 
Dr. Koosa), consisting of inunctions with the oleate of mercury and the 
internal administration of iodide of potassium in large doses (reaching 6 
drachms in a single day on one occasion), brought about, in the course of 
a few weeks, a very marked improvement of the hearing. * (Full details 
with regard to this case will be found on p. 528 of the fourth edition of Dr. 
Koosa's " Treatise on the Ear.") 

Case II. — Female, setat. 40, a teacher, somewhat anaemic, October 6, 
1877. Totally deaf in the right ear since childhood. Two weeks ago she 
began to notice slight deafness in the left ear, together with occasional 
pains and a sense of tightness in the ear. Left drum-membrane apparently 
normal. The ticking of a watch heard at a distance of four feet. Eight 
drum-membrane very much disfigured by inflammation that occurred dur- 
ing childhood. Pharynx healthy. As there are no indications for treat- 
ment, she is advised to wait. 

On the 23d of October she returned. The hearing-power had been 
steadily and even quite rapidly diminishing. Tinnitus constant. On the 
12th she began to experience a sensation of dizziness, which soon became 
so marked that she could only walk with the assistance of a friend. No 

1 It should be stated here that this patient had already been subjected to what 
might be termed an ordinary course of antisyphilitic treatment. Little or no benefit, 
however, resulted. It was not until the more vigorous antisyphilitic plan of treat- 
ment had been instituted — the plan which Dr. Roosa was the first, I believe, to employ 
in these cases of sudden and complete deafness— that decided benefit was obtained. 



400 DIAGNOSIS AND TREATMENT OF 

change in the condition of the drum-membrane. Treatment : iodide of 
potassium in fifteen-grain doses three times a day. 

October 30th. — Slight improvement in the hearing ; dizziness the same. 
Dose of iodide of potassium increased to twenty grains three times a day. 

November 28th. — Hearing is now, so far as she herself can perceive, as 
acute as when I first saw her on the 6th of October. The ticking of the 
watch is heard at a distance of four feet. The dizziness has also disap- 
peared entirely, though a little tinnitus still remains. All treatment is to- 
be stopped. 

From her physician, Dr. Charles Packard, I learn that he has had occa- 
sion to treat her for a suspicious periostitis on both tibiae. The deafness 
was therefore probably due to a syphilitic affection of the auditory nerve, 
or of the labyrinth, or of some structure in its immediate neighborhood. 

Case IH.— Male, setat. 45, in fair general health, March 22, 1876. Eigh- 
teen months ago he became paralyzed on the left side of the body, and also 
discovered that his hearing in the left ear was not as acute as usual. Already 
six months prior to this he had noticed that he sometimes saw double. 
Five months ago he quite suddenly — in the course of a few minutes, he 
says — lost the hearing in his right ear. This was associated with more or 
less dizziness, which has steadily increased from that time to this. He ad- 
mits having had syphilis at the age of thirty -five. On examination, both 
drum-membranes are found to be in a nearly normal condition. 

He was given iodide of potassium in slowly increasing doses, but he 
ceased to visit the Infirmary before any appreciable improvement had yet 
taken place, or could reasonably have been looked for. 

Under the title of anomalies of hearing may be grouped a series of com- 
paratively rare phenomena which are usually considered as being depend- 
ent on lesions confined to the cochlear structures. In this category are in- 
cluded the conditions known as diplacusis monauricularis and binauricu- 
laris, 1 and that known under the designation of limited range of audition. 
No instances of the latter anomaly have as yet come under my observation ;.. 
of the former, however, I have seen three cases. In the first of these, the 
patient, an intimate personal friend, contracted a severe "cold in the head," 
and soon afterward a subacute catarrh developed in the right middle ear. 
"When notes of a rather low pitch were sounded, he heard them as well- 
defined simple musical tones. When, however, the highest tones and even 
those of a moderately high pitch were sounded, the patient heard, besides 
the fundamental tone, a second and less distinct one. His ear not being 
sufficiently cultivated, he was unable to state what was the interval between 

1 Dr. Knapp, of this city, was, I believe, the first to describe and give a name to 
this peculiar anomaly (Arch, of Oph. and Otol., Vol. II.). 



DISEASES OF THE EAR. 401 

these two tones. Furthermore, while suffering in this way he attended a 
public concert, but, instead of deriving pleasure from the music, he experi- 
enced positive discomfort by reason of the great confusion of sounds which 
it produced in his ear. He discovered, however, that when he kept the right 
ear closed, the confusion entirely disappeared, and the musical tones which 
reached his ear appeared to be distinct and harmonious. In the course of 
a few weeks these unpleasant symptoms entirely disappeared. 

In this case, the term diplacusis monauricularis (or double hearing in 
one and the same ear) would be the appropriate expression to use in desig- 
nating the pathological condition. In a second case, the patient, who was 
also suffering at the time from a naso-pharyngeal (and, in all probability, 
tympanic) catarrh, experienced still a different form of annoyance. " When 
I whistled," I quote very nearly his own words as written down at the time 
in my note-book — " I heard in one ear the corresponding (or correct) note, 
but in the other ear I heard a tone which harmonized with the first note ; 
the exact relation of which, however, to the note whistled I am not musical 
enough to state. If I closed the ear that was out of tune I heard only one 
note, and not a chord." As the patient was giving me an account of some- 
thing that had happened before I saw him, I was unable to gather more 
accurate information with regard to several points which suggest themselves 
when we read the above statement. In classifying this case, we might very 
properly designate it by the term diplacusis binauricidaris, the phenomenon 
of double hearing requiring, in this case, both ears for its production. 

In a third case, the patient, a maiden lady about fifty years of age, con- 
sulted me on the 25th of June, 1873, for a slowly increasing deafness, which 
on examination I found to be due to a chronic catarrhal inflammation of 
both middle ears. When I placed the vibrating tuning-fork (C) upon the 
central portion of the forehead, she said that she heard it differently in the 
two ears, that is, lower in the left than in the right. As she knew very 
little about music, she could not tell what the interval was between the two 
notes. She was positive, however, that it was less than an octave. She 
also said that the two notes harmonized. I then held the vibrating fork 
first in front of one ear and then in front of the other, and she still insisted 
that the pitch of the tone heard on one side was lower than that heard on 
the other. 

I greatly regret that I allowed these cases (or at least the first and the 
last ones) to pass out of my hands without first subjecting them to a more 
thorough examination with regard to the behavior of the ears when tested 
with tones of different pitch. Since 1873 I have not had a single opportu- 
nity of making good these deficiencies. But even these three imperfectly 
observed cases offer data that possess a certain degree of value. Thus (in 
the first place), it will be noticed that in all of them there was disease of 
the mucous membrane of the middle ear. In the second place, in the 
first two cases (and, possibly, for aught I know also in the third) the phe- 
26 



402 DIAGNOSIS AND TEEATMENT OF 

nomenon of double hearing disappeared entirely when the catarrh subsided. 
In the third place, there was nothing sudden in the character of the attack, 
nor was there any nausea or giddiness. Finally, in the second case I would 
call attention to the patient's statement that when he closed the ear that 
was out of tune, the symptom of double hearing ceased. Cases of dipla- 
cusis are considered as par excellence cases of disease of the cochlea. It is 
assumed that those particular fibres or sets of fibres in the organ of Corti, 
which normally should vibrate in sympathy with a different tone from that 
sounded, become so altered in their tension or in their loading that they 
too respond to the tone in question, and so send a wrong communication 
to the brain. If such be the true state of things in these cases of diplacu- 
sis, why should the closing of the affected ear — which implies the nearly 
total exclusion of those sound impulses that would naturally reach the laby- 
rinth by way of the membrana tympani and chain of ossicles, put a stop 
to the phenomenon of double hearing ? The vibrations of the air in the 
patient's mouth, as he continued to whistle, must, under these circum- 
stances, have been transmitted to the cochlea of the affected (or mis-tuned) 
ear through the intervening bony structures, without the aid of the 
mechanism of the middle ear, and, finding there a healthy organ of Corti, 
these vibrations then produced effects which caused correct impressions to 
be transmitted to the brain. If this phenomenon can be verified in other 
similar cases, it will go far toward demonstrating the possibility that the 
mechanism of the middle ear may be so mis-tuned as to allow certain har- 
monics of the note sounded to exert a preponderating influence upon its 
mode of vibration, and thus to excite unduly the corresponding portions of 
Corti's organ. 1 

I bring forward these points, not because I wish my readers to adopt 
these views, but simply because I wish to impress upon them the necessity 
of waiting for further proofs before they unhesitatingly adopt any view. I 
am myself utterly in the dark with regard to all this category of assumed 
labyrinthine diseases, and I think we should endeavor to collect, with minds 
unprejudiced in favor of any particular view, further facts. In this way, 

1 Patients suffering from catarrhal inflammation of the middle ear sometimes com- 
plain of a symptom which might perhaps be described as a diplacusis monauricularis. 
While singing, or when standing near to an individual who is singing, such patients 
experience at times an unpleasant jarring sound in one ear. During a part of one 
winber, several years ago, I suffered from this symptom to such a degree that it was 
very unpleasant for me to take part in chorus-singing. It was only when the higher 
notes were sounded that this symptom manifested itself. The sensation then produced 
was as if sympathetic vibration had been excited either in the chain of ossicles or in 
eome other part of the middle or external ear. The high tone thus generated could 
be felt as well as heard, and the sensation produced was partly that of a musical tone 
and partly that of a jarring. I was not able to define the relationship of this un- 
pleasant tone to that which called it into existence. My recollection is, however, that 
it was much higher than the latter. 



DISEASES OF THE EAE. 403 

and in this way only, shall we be able to reach conclusions that will bear 
the test of time. 

In a few cases I have observed the condition usually designated as hy- 
peresthesia acustica. The individuals so affected were invariably of a nervous 
temperament, and I have always looked upon the symptom rather as an 
evidence of an overstrained nervous system, than as a manifestation of any 
disturbance of a peculiarly aural type. 

The condition known as boiler-makers' deafness is usually classed among 
the labyrinthine affections. It is not known what are the precise lesions upon 
which the deafness depends, but it is supposed that the violent concussions, 
to which the cochlear structures are almost incessantly subjected, cause such 
a relaxation of these parts that they lose the power of responding to the 
more delicate vibrations of the sounds produced in ordinary conversation. 
In the course of time, it is probable that a certain degree of thickening and 
rigidity takes place in consequence of the frequently repeated mechanical 
violence done to the parts. In the few cases which I have had an opportunity 
of examining, the drum-membrane invariably appeared to be much thicker 
and tougher than is natural, and from this circumstance I have sometimes 
thought that boiler-makers, perhaps, owed their deafness in part to the great 
changes in temperature to which they are exposed. It is more likely, how- 
ever, that the thickening referred to is dependent upon the prolonged 
irritation caused by the concussions of the air. 

I should perhaps refer in brief terms to the diagnosis, prognosis, and 
treatment of the class of cases referred to in the present chapter. 

If, in the course of scarlet fever, measles, typhoid fever, or cerebro-spinal 
meningitis, a sudden loss of the hearing-power takes place, we may at once 
suspect that the lesions are either intracranial or labyrinthine. If, on exam- 
ination, we fail to find any adequate cause for the deafness in the condition 
of the external or middle ear, we may feel as positive, with regard to the 
correctness of our diagnosis, as it is possible to be in the present state of 
otologica! knowledge. If the deafness is confined to one ear, the tuning- 
fork will be found of great value in corroborating our suspicions. It is not 
an indifferent matter what sort of a tuning-fork we use for this purpose. If 
the instrument be too small and of too high a pitch, we shall find it utterly 
unfit for use. No matter how quick our movements may be, we shall 
barely have time to plant the vibrating fork on the patient's forehead before 
its vibrations will have become so feeble that to the patient they will be 
inaudible. In all the instrument-makers' shops it is now an easy matter to 
purchase forks of low pitch and so constructed that they maintain suffi- 
ciently vigorous vibrations for a period of several seconds — that is, long 
enough for the surgeon to deliberately place the vibrating fork on the pa- 



404 DIAGNOSIS AND TREATMENT. 

tient's head, and for the patient then to quietly observe in which ear he 
hears the sound best. In the class of cases which we are now considering, 
the sound of the vibrating fork, placed on the bridge of the nose or in the 
median line of the forehead, will be heard best or exclusively in the unaf- 
fected ear ; while if the affection be due to some disturbance in the middle 
ear (the drum-membrane still being entire), the sound will probably be 
heard best in the affected ear. In children the test is of doubtful value at 
best. 

The mode of development of the deafness (as, for example, in the cases 
of Meniere's disease) will also aid us greatly in arriving at a correct diagno- 
sis. In every doubtful case it behooves us to remember the possibility of 
a syphilitic origin. No harm can come from the assumption, in any given 
case, that the disease is of syphilitic origin ; but the failure to recognize 
such a cause may under certain circumstances deprive the patient of a cure 
which is perhaps within reach. 

The prognosis, in all the different cases of this class, is bad ; and yet now 
and then recoveries are observed. I can recall a single case of total deaf- 
ness in one ear, following an attack of scarlet fever, in which the hearing, 
after the lapse of about two weeks, gradually returned to a fair degree of 
acuteness. The case of syphilitic deafness treated by Dr. Koosa (p. 399) 
affords a good illustration of what may sometimes be accomplished in this 
form of the disease. In " Meniere's disease " the prognosis is decidedly bad. 
In those cases in which the hearing is only partially lost, a certain degree 
of improvement may afterward take place ; in the great majority of cases, 
however, the damage is permanent. The deafness produced by cerebro- 
spinal meningitis may be considered as the most hopeless of all the known 
forms of sudden or rapid loss of hearing. 

So far as the treatment is concerned, I have very little experience of my 
own to offer. The iodide of potassium afforded some relief in one or two 
cases ; in another, the course of treatment recommended by Dr. Brown- 
Sequard (see p. 396) ameliorated the patient's condition in other respects, 
but failed to improve the hearing ; finally, in a third, a vigorous antisyphili- 
tic treatment so far restored the patient's hearing that he was able to hear 
ordinary conversation fairly well. I have not sufficient faith in the efficacy 
of electricity or galvanism, in cases of this kind, to justify me in urging a 
patient to make a trial of them. 



INDEX. 



Absolute alcohol, in the treatment of 

granulation-growths, 256 
Acetum cantharidis, in the treatment of 

eczema, 39 
Acid nitrate of mercury, employment of as 

a caustic, 258 
Acoumeter, Politzer's, 19 
Adenoid vegetations, naso-pharyngeal, 171 
Adhesions in the middle ear, 271 
Aerial distention of the middle ear, 155 
Air-cells of the mastoid process, variations 

in the size of, 297 
Alcohol, absolute, in the treatment of 

granulation-growths, 256 
Alum, burned, employment of, in the 
treatment of granulation-growths, 257 
powdered, in the treatment of naso- 
pharyngeal catarrh, 169 
solutions, introduction of into the mid- 
dle ear dangerous, 337 
Ampullas of membranous semicircular 

canals, 8 
Aneurism of posterior auricular artery, 365 

of the middle ear, 380 
Angioma cavernosum of auricle, 54 
Angular forceps, 28 
Annulus tympanicus, 25 
Anomalies of hearing, 400 
Antrum (mastoid), acute inflammation of, 
304 

caries of, 315 

chronic subacute purulent inflamma- 
tion of, 301 
relations of, to external auditory canal, 

363 
relations of, to facial canal, 361 
Anvil, anatomical relations of, 3 



Arsenite of potassa, in the treatment of 

eczema, 37 
Artificial drum-membrane of Toynbee, 277 
Aspergillus, growth of, in auditory canal, 

79 
Astringents, employment of in the treat- 
ment of granulation-growths, 257 
Atrophied drum-membrane, slight regen- 
erative power of, 144 
Audition, limited range of, 400 
Auditory canal, cysts of, 123 

desquamative inflammation of, 86 

diffuse inflammation of, 74 

diseases of, 57 

eczema of, 74 

false membranes in, 98 

foreign bodies in, 109 

furuncles of, 65 

horizontal surface motion in, 57 

in the infant, 25 

new-growths in, 114 

relations of to neighboring organs, 1 

syphilitic ulcers and condylomata of, 
104 

ulcers of, 92, 249 

wounds of, 113 
Auditory nerve, syphilitic disease of, 398 
Auricle, angioma cavernosum of, 54 

cirsoid aneurism of, 54 

cleft lobule of, 54 

congenital malformations of, 55 

contusions of, 54 

cornu humanum of, 52 

diseases of, 35 

eczema of, 35 

epithelioma of, 51 

fibroid tumors of, 51 



406 



INDEX. 



Auricle, herpes zoster of, 53 
inflammation of, 39 
perichondritis of, 40 
syphilitic disease of, 53 
ulcers of, 45 



Benzoated oxide of zinc ointment, in the 

treatment of eczema, 39 
Blake's middle-ear syringe, 191 

snare, 253 
Bleeding from the ear, significance of, in 

cases of supposed fracture of the tem- 
poral bone, 289 
Bloodletting by leeches, value of, in acute 

inflammation of the middle ear, 216 
Body-temperature, in mastoid affections, 

362 
Boettcher, Arthur, on the function of the 

semicircular canals, 392 

experiments with regard to the func- 
tion of the semicircular canals, 15 
Boiler-maker's deafness, 403 
Bone-drills for establishing an opening in 

the mastoid process, 308 
Bone-caries in the external auditory canal, 

95 
Boracic acid, employment of, in cases of 

otitis media purulenta, 224 
Bright spot of the membrana tympani, 

126 
Bulb-syringe, 33 

Bullet, removal of, from ear, 285 
Burnett, onaspergillus in external auditory 

canal, 81 

on horizontal motion in the external 
auditory canal, 103 

Cade, oil of, in the treatment of eczema, 
38 

Caerumen, impacted, 57 

Calcareous deposits in the drum-mem- 
brane, 270 

Calcareous mass in the auditory canal, 
93 

Canalis reuniens, 8, 13 

Cancer of external auditory canal, 118 

Caries, primary, of the external auditory 
canal, 97 

Carious processes in the middle ear, 259 

Carotid artery, ulceration of, and fatal 
hemorrhage, 269 



Catarrh, definition of the term, 142 

Catarrhal inflammation of the middle ear, 
153 

Caustics, employment of, in cases of poly- 
poid growths, 254 

Cerebro-spinal meningtis, a frequent cause 
of labyrinthine disease, 389 

Cheesy inflammation of the middle ear, 
244 

Chondromalacosis of the auricle, 40 

Chorda tympani nerve, affections of, 269, 
387 

Chromic acid, employment of as a caustic, 
256 

Chronic subacute catarrh, 193 

Cicatrices of the drum-membranes, 271 

Cicatricial drum-membranes, rupture of, 
132 

Cirsoid aneurism of auricle, 54 

Clark's douche, 215 

Cleft lobule of auricle, 54 

Cochleal whorl, transverse section of, 10 

Columella, in the ear of the sea-turtle, 3 

Condylomata of external auditory canal, 
104 

Contrecoup, fractures by, 279 

Contusions of auricle, 54 

Copper, sulphate of, as a caustic, 256 

Cord-like bridge of flesh in the auditory 
canal, 99 

Cornu humanum of auricle, 52 

Corti's membrane, 10 

Corti's organ, definition of the term, 14 
mechanism of, 12 

Cotton-holders, 29, 166 

value of, in cleaning the auditory 
canal, 232 

Curettes, 30 

Cupola of cochlea, 12 

Cuticular membrane in the external audi- 
tory canal, 104 

Cyst-like tumors of the drum-membrane,. 
269 

Cysts of the auditory canal, 123 

Deformity of drum-membrane, 372 

Deformities caused by purulent inflamma- 
tion of the middle ear, 270 

Desquamative inflammation of the external 
auditory canal, 86 

Desquamative processes in the middle ear, 
265 



INDEX. 



407 



Diachylon ointment, Eebra's, in the treat- 
ment of eczema, 38 
Diet in eczema, 36 
Diplacusis, monauricularis and binauricu- 

laris, 400 
Diploetic spaces of the mastoid process, 

29G 
Drills, for perforating the mastoid process, 

368 
Donble-curved Eustachian catheters, 139 . 
Double hearing, 400 

Double perforations in the drum-mem- 
brane, 228, 275 
Douche, aural, 33 

Douche, nasal, its use a cause of acute in- 
flammation of the middle ear, 152 
Drum- membrane, atrophy of, 370 
cicatrices of, 271 
cyst-like tumors of, 269 
deformity of, 372 
double perforations in, 228, 275 
paracentesis of, 181 
reproduction of, 273 
rupture of, 373 
Dry cups, in the treatment of acute inflam- 
mation of the middle ear, 216 
Ductus cochlearis, 8 



Ear disease and life insurance, 236 
Ear- douche, simple pattern of, 34 
Ear-nozzle, pronged variety, 33 
Ear-specula, 20 
Eczema of the auditory canal, 74 

of the auricle, 35 
Electricity, in the treatment of diseases of 

the labyrinth, 404 
Epithelial masses, laminated, in the mid- 
dle ear, 265 
Epithelioma of auricle, 51 
Erysipelas, facial, following Wilde's inci- 
sion, 330 
Eustachian bougies, medicated, 176 
Eustachian catheters, 134 

mode of introducing them, 136 
Eustachian tube, closure of, 144 

function of, 1 

narrowing of, 143 

simple catarrh of, 142 

spasmodic contractions of muscles of, 
147 

unnatural patency of, 145 



Examination of the ear, rules for, 26 
Exostoses of the external auditory canai, 

115 
External auditory canal, relations of, to 

neighboring organs, 1 



Facial canal, relations of, to antrum, 361 
Facial paresis or paralysis, in mastoid af- 
fections, 361 
False membranes in the auditory canal, 98 

in the middle ear, 274 
Faucial catheter, 139 
Fenestra rotunda, 6 
Fibrinous exudation in acute inflammation 

of the middle ear, 205 
Fibroid tumors of auricle, 51 
Forceps, angular, 28 
Hinton's, 253 
Politzer's, 29 
Forehead-mirror, for aural examinations, 
22, 34 

mode of employing it, 34 
Foreign bodies in the external auditory 
canal, 109 
in the middle ear, 258 
Fowler's solution in the treatment of ec- 
zema, 37 
Fractures of the temporal bone, 278 
Furuncles of the auditory canal, 65 
of the auricle, 39 



Galvanism, in the treatment of diseases 
of the labyrinth, 404 

Galvano- cautery, employment of, for re- 
moval of polypoid growths, 258 

Giampetro-Lowenberg method of intro- 
ducing the Eustachian catheter. 138 

Granulation-tissue, formation of, in middle 
ear, 246 

Green, J. Orne, on exudations of fibrin 
into the middle ear, 205 

Grubers specula, 21 

Gummata of auricle, 53 

Gunshot wounds of the ear, 285 



Hematoma auris, 40 
Hammer, absence of, 372 

anatomical relations of, 3 
Hand -mirror, for aural examinations, 22 
Handle of hammer, hook-shaped, 373 



408 



INDEX. 



Hearing, anomalies of, 400 
physiology of, 1 

Hearing -cells, inner and outer, 10 

Heat, moist or dry, in the treatment of 
furuncles of the auditory canal, 72 

Hebra's diachylon ointment in the treat- 
ment of eczema^ 38 

Helicotrema, 12 

Helmholtz theory of hearing, 12 

Hemorrhage, in removal of polypi, 255 

Hemorrhagic exudation into the middle 
ear, 164 

Herpes roster of auricle, 53 

Hewett, Prescott, on fractures of the base 
of the skull, 289 

Horizontal motion in the external auditory 
canal, 103 

Hinton's polypus-forceps, 253 

Hook-shaped handle of hammer, 373 

Horny growth of the rnembrana tympani, 
371 

Hot douche, value of, in acute inflammation 
of the middle ear, 215 

Howe, on deformed auricle, 48 

Hun, on othematoma of the insane, 41 

Hyperesthesia acustica, 403 

Hyperostosis of the bony wall of the tym- 
panum, 374 

of the external auditory canal, 114 



Ice, employment of, in the treatment of 
acute inflammation of the middle ear, 
216 

Incisions, in furuncles of the external au- 
ditory canal, 69 

Inflations of the middle ear, therapeutic 
action of, 178 

Intermittent deafness, 390 

Intratympanic medication, 188, 220 
vascular growths, 375 

Iodine, tincture of, application to the mas- 
toid integuments, 181 

in the treatment of naso -pharyngeal 
catarrh, 169 

Iodoform, employment of, in the treat- 
ment of granulation-growths, 257 



Kipp, on angioma cavernosum of auricle, 
54 

on spurious othematoma, 44 



Knapp, Herman, on malignant tumors of 
the middle ear, 382 



Labyrinth, anatomical relations of, 7 

Labyrinth, diseases of, 388 

Lamina reticularis, 10 

Lamina spiralis ossea, 10 

Laminated epithelial masses in the middle 

ear, 265 
Larvse of the house-fly in the auditory 

canal, 110, 249 
Lateral sinus, phlebitis of, 295 
Leeches, employment of, in furuncles of 

the auditory canal, 73 
in mastoid affections, 364 
Life insurance and ear disease, 236 
Ligamentum spirale, 10 
Light, sources of, for aural examinations, 

25 

Malformations, congenital, of auricle, 55 
Malignant tumor of the middle ear, 382 
Malleo-incudal joint, 3 
Mastoid cells, caries of, 339 

inflammation of, 328 
Mastoid process, anatomy of, 296 

establishment of an opening in, 366 
integuments of, tenderness, redness, 

and swelling of, 359 
periostitis, 355 
Mathewson on exostoses of the external 

auditory canal, 118 
Mayer, experiments of, with relation to the 

transmission of composite sounds, 6 
Membrana basilaris, 8 
Membrana flaccida, 207 
Membrana tectoria, 10 
Membrana tympani, almost entire repro- 
duction of, 248 
atrophy of, 370 
changes in position of, 126 
relations of to hammer, 3 
Membrana tympani secundaria, 6 
Meniere's disease, 391, 404 
Meningitis, from acute inflammation of 

the mastoid antrum, 306 
Mercury, acid nitrate of, as a caustic, 256 
Metastatic abscesses, in mastoid affections, 

361 
Meyer, on naso-pharyngeal adenoid vege- 



INDEX. 



409 



Middle ear, catarrhal inflammation of, 153 
fluid exudation in, 127 
methods of examining it, 125 
new-growths in, 374 
purulent inflammation of, 196 
syphilitic disease of, 227 

Middle-ear pipettes, 188 

Mucus, accumulation of, in the tympanic 
cavity, 159, 336 

removal of, from tympanum, 180 

Murmurs, systolic, subjective and objec- 
tive, 386 

Myringotome, 182 

Narrowing of the Eustachian tube, 143 
Nasal douche, employment of, may cause 
acute inflammation of the middle ear, 
152 
Xasal passages, obstruction of, a cause of 

deafness, 155 
Xaso-pharyngeal adenoid vegetations, 171 

catarrh, treatment of, 166 
Xecrosis of the temporal bone, 264 
New-growths in the external auditory 
canal, 114 

in the middle ear, 374 
Nitrate of silver, in eczema of the auditory 
caual, 38, 83 

pure, in the treatment of granulation- 
growths, 256 
solutions, in otitis media purulenta, 

222 
solutions of, in treatment of naso- 
pharyngeal catarrh, 166 
Nitric acid, employment of, in cases of 

polypoid growths, 256 
Nose-piece of Politzer's apparatus, 131, 134 
Noyes, on double- curved Eustachian cath- 
eters, 139 

Ocular symptoms, in mastoid affections, 
363 

Oil of Cade, in the treatment of eczema, 

38 
Ossicles, destruction of, 275 
Otalgia, 387 
Otomycosis, 74 
Othsematoma, 40 

Paest, significance of, in mastoid diseases, 
358 



Palato-tubal muscles, paresis of, 148 

Papillomata, syphilitic, of external audi- 
tory canal, 106 

Paracentesis of the drum-membrane, 181, 
218 

Paresis or paralysis of the facial, in mastoid 
affections, 361 

Parotid abscess following typhoid fever, 92 

Patency, unnatural, of the Eustachian tube, 
145 

Pearl-like thickenings of the drum-mem- 
brane, 271 

Perichondritis of the auricle, 40 

Periostitis, mastoid, 355 

Pillars of Corti, inner and outer, 10 

Pipette3 for introducing fluids into the 
middle ear, 188, 222 

Pneumatic spaces of the mastoid process, 
296 

Politzer's acoumeter, 19 
forceps, 29 

method of inflating the middle ear, 
129 

Polypoid growths in auditory canal. 94 
removal of, 252 

Polypus snare, Blake's, 253 

Pomeroy, on othematoma, 46 
on impacted cerumen, 59 
faucial catheter, 139 

Porte-acid, 255 

Posterior fold, acute inflammation of, 224 

Potassa solution, solvent action of, upon 
cerumen, 63 

Poultices, in treatment of mastoid affec- 
tions, 364 

Pouting character of perforations, 208 

Powdered remedies, in the treatment of 
otitis media purulenta, 223 

Probes, 30 

Prolapse of upper cutaneous wall of audi- 
tory canal, in mastoid affections, 363 

Proliferative form of otitis media puru- 
lenta chronica, 246 

Pronged hard-rubber ear-nozzle. 33 

Prout's method of recording the hearing- 
power, 19 

Psychical phenomena, in mastoid affec- 
tions, 362 

Putzel, Dr. L. , on injury to the fifth nerve, 
295 

Pyasmic symptoms in mastoid affections, 
362 



410 



INDEX. 



Quinine, acute inflammation of middle 
ear caused by, 152 



Reflectors, 22 

use of, in aural examinations, 24 
Reissner's membrane, 10 
Reproduction of the drum - membrane, 

248 
Roosa, on othematoma, 47 

on the treatment of syphilitic affec- 
tions of the ear, 899 
Rosenmuller's fossa, 138 
Ruptures of the drum-membrane, 373 



Saccule, 8 

Safety-tube of Eustachian canal, 1 

Sarcoma, primary, of the external auditory 

canal, 120 
Scala tympani, 8 
Scala vestibuli, 8 
Sclerosis of the mastoid process, 299 

of the tympanic mucous membrane, 
193 
Sea-turtle, auditory apparatus of, 2 
Semicircular canals, function of, 15, 392 

transverse section of, 15 
Septicsemic symptoms in mastoid affec- 
tions, 362 
Serous exudation into the middle ear, 159 
Shrapnell's membrane, 126, 207 
perforations in, 226 
inflammation of, in cases of supposed 
fracture of the temporal bone, 293 
Siegle's pneumatic speculum, 127 
Silver nitrate, in the treatment of eczema, 
38 

pure, in the treatment of granulation- 
growths, 256 
Snapping noises in the ear, 147 
Soda solution, solvent action of, upon 

cerumen, 63 
Spasmodic contractions of the muscles of 

the Eustachian tube, 147 
Specula, aural, 20 

employment of, as dilators, 65 
how they should be introduced, 24, 
27 
Stapedio-vestibular articulation, 4 
Stirrup, anatomical relations of, 3 
expulsion of, 378 



Sulphate of copper, as a caustic, 256 

Syphilitic disease of the middle ear, 227 
of the labyrinth, 398 

Syringes, 31 

Syringing, for the removal of impacted 
cerumen, 64 

Systolic murmurs, subjective and objec- 
tive, 386 



Temperature of the body in mastoid af- 
fections, 362 
Temporal bone, fractures of, 278 
Temporo - maxillary joint, arthritis of, 

387 
Tenderness on pressure over the mastoid 

region, 359 
Tests of the hearing-power, 17 
Tonsils, enlarged, treatment of, 175 
Toynbee's artificial drum-membrane, 277 

specula, 21 
Tubercular cases of otitis media purulenta, 

244 
Tympanic cysts, 269 



Ulceration of the cutaneous walls of the 

external auditory canal, 249 
Ulcers of auditory canal, 92 
of the auricle, 45 

syphilitic, of external auditory canal, 
104 
Utricle, 8 



Valsalva's method of inflating the mid- 
dle ear, 128 

Vascular growths of the membrana tym- 
pani, 372 

in the middle ear, 375 

Vaseline, in the treatment of eczema, 89 

Vegetations, syphilitic, of the external 
auditory canal, 106 

Vestibule, or central cavity of the laby- 
rinth, 7 

Voltolini, on primary acute inflammation 
of the labyrinth. 391 

Von Troeltsch's specula, 21 



Warts, syphilitic, of external auditory 
canal, 107 



INDEX. 



411 



Washing out the middle ear, 190 

Watch, ticking of, as a test, 17 

Watery discharge from the ear, signifi- 
cance of. in cases of supposed fracture 
of the temporal bone, 293 

Weir, Robert F., on intratympanic vascu- 
lar growths, 375 

Wilde 8 incision, 365 
specula, 21 



Words, whispered or spoken, as tests of 

the hearing, 117 
Wounds of the auditory canal, 113 

Zaufai/s nasal specula. 139 

Zinc ointment, in the treatment of eczema, 

S9 
Zuckerkandl, on anatomy of the mastoid 

process, 296 



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